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Theories Guiding Nursing Research and Practice : Making Nursing Knowledge Development Explicit [1 ed.]
 9780826164056, 9780826164049

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Theories Guiding Nur sing Research and

Pr actice

M a k ing Nur sing K now ledge De v elopment Explicit

Joyce J. Fitzpatr ick • Ger a ldine M c C a rth y Editor s

Theories Guiding Nursing Research and Practice

Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, is Elizabeth Brooks Ford professor of nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University (CWRU) in Cleveland, Ohio, where she was dean from 1982 through 1997. She holds an adjunct position as professor in the Department of Geriatrics, Mount Sinai School of Medicine, New York, New York. She earned a bachelor of science in ­nursing (BSN; Georgetown University), a master of science (MS) in psychiatric–mental health nursing (The Ohio State University), a PhD in nursing (New York University), and an MBA from CWRU in 1992. In 1990, Dr. Fitzpatrick received an honorary doctorate, Doctor of Humane Letters, from her alma mater, Georgetown University. In 2011, she received an honorary doctorate, Doctor of Humane Letters, from the Frontier University of Nursing. She has received numerous honors and awards; she was elected a fellow in the American Academy of Nursing in 1981 and a fellow in the National Academies of Practice in 1996. She has received the American Journal of Nursing Book of the Year Award 18 times. Dr. Fitzpatrick is widely published in nursing and health care literature with more than 300 publications. She served as ­coeditor of the Annual Review of Nursing Research series, volumes 1 through 26; she edits the journals Applied ­Nursing Research, Archives in Psychiatric Nursing, and Nursing Education Perspectives, the official journal of the National League for Nursing. She edited three editions of the classic Encyclopedia of Nursing Research (ENR), as well as a series of nursing research digests. Dr. Fitzpatrick’s research has focused on meaningfulness in life, notably the meaningfulness of nurses’ work life related to satisfaction, turnover, leadership, engagement, and empowerment. Geraldine McCarthy, PhD, RGN, is emeritus professor at the Catherine McAuley School of Nursing and Midwifery University College Cork (UCC). She was founding head and dean of the school, which was established in 1996. She holds a diploma in nursing from University College Dublin, MEd degree from Trinity College Dublin, and MSN and PhD degrees in nursing from Case Western Reserve University, Cleveland, Ohio. From 2010 to 2011 she held the post of acting head of the College of Medicine and Health at UCC, providing strategic leadership in research and educational programs across the Schools of Medicine, Nursing and Midwifery, Pharmacy, Therapies, and Dentistry. She has been a member of a number of national and international bodies including the Nurse Education Forum, the Task Force on Undergraduate Medical Education, and was a ministerial nominee to the Commission on Nursing, Health Information and Quality Authority and the Fulbright Commission. Presently, she is a member of the advisory board for the Reconfiguration of the Health Services in the Southern Region and Marymount Hospital Board. As emeritus professor, Dr. McCarthy supervises PhD-level research and leads and coordinates the doctorate in nursing program that prepares nurses to function as advanced leaders in diverse settings. She has also participated in European Union–funded projects including one on developing leaders in medicine in Slovakia and European Union–funded projects (FIRE and ELLAN) with colleagues from European countries on facilitating implementation of research evidence. She has published more than 130 original articles, edited 7 books, authored/coauthored 9 book chapters, and served on several editorial boards of nursing and health care journals. In 2013, she received an appointment from the Minister of Health for Ireland to chair the South/South West Region Health Care Board, serving as the only nurse to chair one of the six regional health boards.

Theories Guiding Nursing Research and Practice Making Nursing Knowledge Development Explicit

Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN Geraldine McCarthy, PhD, RGN Editors

Copyright © 2014 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Margaret Zuccarini Composition: Amnet Systems ISBN: 978-0-8261-6404-9 e-book ISBN: 978-0-8261-6405-6 14 15 16 17 / 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. Because medical science is continually advancing, our knowledge base continues to expand. Therefore, as new information becomes available, changes in procedures become necessary. We recommend that the reader always consult current research and specific institutional policies before performing any clinical procedure. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Theories guiding nursing research and practice : making nursing knowledge development explicit / [edited by] Joyce J. Fitzpatrick, Geraldine McCarthy. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8261-6404-9 (print : alk. paper) — ISBN 978-0-8261-6405-6 (e-book) I.  Fitzpatrick, Joyce J., 1944– editor.  II.  McCarthy, Geraldine, 1950–, editor. [DNLM:  1.  Nursing Theory.  2.  Nursing Research.  3.  Nursing.  WY 86] RT81.5 610.73072—dc23 2014005582 Special discounts on bulk quantities of our books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. If you are interested in a custom book, including chapters from more than one of our titles, we can provide that service as well. For details, please contact: Special Sales Department, Springer Publishing Company, LLC 11 West 42nd Street, 15th Floor, New York, NY 10036-8002 Phone: 877-687-7476 or 212-431-4370; Fax: 212-941-7842 E-mail: [email protected] Printed in the United States of America by Bradford & Bigelow.

Contents

Contributors

vii

Foreword ix Pamela G. Reed, PhD, RN, FAAN Preface

xi

Acknowledgments

xiii

Share Theories Guiding Nursing Research and Practice Part I: Introduction

 1. The Discipline of Nursing   3 Joyce J. Fitzpatrick  2. Extant Nursing Models and Theories: Grand and Middle Range Theories in Nursing   15 Mary T. Quinn Griffin and Margaret G. Landers Part II: Theories Applied to Research

 3. Symptom Management Theory   35 Margaret G. Landers  4. Transitions Theory   51 Alice Coffey  5. Theory of Planned Behavior   69 Nicola Cornally  6. Social Support Theory   85 Patricia Leahy-Warren  7. The Health Action Process Approach Theory   103 Elaine Lehane  8. The Judgment to Delay Model   125 Máirín O’Mahony

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Contents

 9. The Progressively Lowered Stress Threshold Model   141 Mark P. Tyrrell 10. Cultural Competence Model   159 Karen Bauce 11. Interpersonal Relations in Nursing Theory   173 Jeffrey S. Jones 12. Theory of Work Engagement   183 Margaret O’Connor Murphy 13. Sexuality in Women: Theoretical Perspectives   201 Vicki Cleary, Aileen Burton, and Josephine Hegarty 14. Acculturation Theory   225 Emerson E. Ea Part III: Theories Applied to Future Research and Practice

15. Story Theory   239 Patricia Prufeta 16. Self-Transcendence Theory   251 Jean Marie DiNapoli, Mary Joy Garcia-Dia, Leila Garcia-Ona, Deirdre O’Flaherty, and Jennifer Siller 17. Theory of Human Caring   269 Catrina Heffernan 18. Transformational Leadership   287 Robin Krinsky and Josiane Hickson 19. Theory of Empowerment   303 Jean Marie DiNapoli, Deirdre O’Flaherty, and Mary Joy Garcia-Dia 20. Theory of Meaning   323 Elizabeth Weathers and Margaret Murphy Part IV: Other Theory Dimensions

21. Theory Underlying Nursing Intervention Research   341 Dianne Morrison-Beedy and Bernadette Mazurek Melnyk 22. Summary and Future Directions   355 Geraldine McCarthy and Joyce J. Fitzpatrick Index  363

Contributors

Karen Bauce, DNP, RN Adjunct Faculty Sacred Heart University Fairfield, Connecticut Aileen Burton, MSc, RGN College Lecturer Catherine McAuley School of Nursing and Midwifery University College Cork Cork, Ireland Vicki Cleary, PhD, RGN Gynaecology Oncology Liaison Nurse Specialist Cork University Maternity Hospital Cork, Ireland Alice Coffey, PhD, RGN College Lecturer Catherine McAuley School of Nursing and Midwifery University College Cork Cork, Ireland Nicola Cornally, PhD, RGN Lecturer Practitioner Catherine McAuley School of Nursing and Midwifery Center for Gerontology and Rehabilitation University College Cork Cork, Ireland Jean Marie DiNapoli, MS, RN Clinical Nurse Manager Mount Sinai Medical Center New York, New York

Emerson E. Ea, DNP, APRN Clinical Assistant Professor Fellow, Hartford Institute for Geriatric Nursing New York University College of Nursing New York, New York Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN Elizabeth Brooks Ford Professor of Nursing Frances Payne Bolton School of Nursing Case Western Reserve University Cleveland, Ohio Mary Joy Garcia-Dia, MA, RN Associate Director Clinical Applications for Information Technology Mount Sinai Medical Center New York, New York Leila Garcia-Ona, MA, RN Nurse Practitioner Mount Sinai Medical Center New York, New York Mary T. Quinn Griffin, PhD, RN, FAAN Associate Professor Frances Payne Bolton School of Nursing Case Western Reserve University Cleveland, Ohio Catrina Heffernan, MSc, RGN Lecturer, Department of Nursing and Health Care Sciences Tralee Institute of Technology Tralee Co. Kerry, Ireland

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Contributors

Josephine Hegarty, PhD, RGN Professor of Nursing Catherine McAuley School of Nursing and Midwifery University College Cork Cork, Ireland

Dianne Morrison-Beedy, PhD, RN Senior Associate Vice President USF Health Dean College of Nursing University of South Florida Tampa, Florida

Josiane Hickson, EdD, RN Assistant Professor Teachers College Columbia University New York, New York

Margaret Murphy, MSc, RN Lecturer Practitioner Catherine McAuley School of Nursing and Midwifery University College Cork Cork, Ireland

Jeffery S. Jones, DNP, PMHCNS Clinical Nurse Specialist Mansfield, Ohio

Margaret O’Connor Murphy, DNP, RN Chief Nursing Officer and Associate Executive Director Long Island Jewish Medical Center New Hyde Park, New York

Robin Krinsky, MSN, RN Adjunct Lecturer Department of Nursing Herbert H. Lehman College Bronx, New York Margaret G. Landers, PhD, RGN College Lecturer Catherine McAuley School of Nursing and Midwifery University College Cork Cork, Ireland

Deirdre O’Flaherty, MSN, APRN Senior Administrative Director Patient Care Services Lenox Hill Hospital New York, New York Máirín O’Mahony, PhD, RGN College Lecturer Catherine McAuley School of Nursing and Midwifery University College Cork Cork, Ireland

Patricia Leahy-Warren, PhD, RGN Senior Lecturer Catherine McAuley School of Nursing and Midwifery University College Cork Cork, Ireland

Patricia Prufeta, MS, RN Director of Surgical Nursing New York-Presbyterian/Weill Cornell Medical Center New York, New York

Elaine Lehane, PhD, RGN College Lecturer Catherine McAuley School of Nursing and Midwifery University College Cork Cork, Ireland

Jennifer Siller, MSN, ACNP-BC Quality Management Specialist Department of Emergency Medicine Lenox Hill Hospital New York, New York

Bernadette Mazurek Melnyk, PhD, RN Associate Vice President for Health Promotion Dean and Professor College of Nursing The Ohio State University Columbus, Ohio

Mark P. Tyrrell, PhD, RGN College Lecturer Catherine McAuley School of Nursing and Midwifery University College Cork Cork, Ireland

Geraldine McCarthy, PhD, RGN Emeritus Professor Catherine McAuley School of Nursing and Midwifery University College Cork Cork, Ireland

Elizabeth Weathers, BSc, RN PhD Student Catherine McAuley School of Nursing and Midwifery University College Cork Cork, Ireland

Foreword Joyce J. Fitzpatrick and Geraldine McCarthy’s book is a distinct and welcome addition to our repertoire of nursing theory texts. It marks a new phase of education in nursing theory. Now that we have adequately addressed the what of nursing theory in several excellent textbooks, it is time to better understand how nursing theories are developed and used in research to advance knowledge for practice. The need for more nurses with doctoral levels of education is generating greater demand for nursing knowledge and importantly—as the title of this new book spells out—for making nursing knowledge development explicit. As the number of nurses who practice using knowledge derived from the disciplinary perspective of nursing increases, so must their engagement in knowledge development. Fitzpatrick and McCarthy’s vision provides an in-depth look into the process of applying nursing theories in research to build knowledge for practice. The process is not simple even though it may be portrayed as one step in research texts. As this book illustrates, theory application involves historical review of the theory; analysis of theory assumptions and components; evaluation of theory for developing the nursing focus, research questions, design, and measurement approaches; and incorporating theory in interpreting results and translating findings for nursing practice. Nursing students will benefit from the contributing authors’ insights and descriptions of the complexities of building knowledge, notably their reasoning in developing, modifying, and evaluating theories. Sometimes the process requires formation of what the authors call neotheory to bridge gaps between extant theory and the practicebased realities of the current problem under investigation. Sometimes the process requires a new instrument to measure concepts relevant to practice. Always the process is innovative. There is no formula for knowledge development, but there are specific activities that facilitate the process, as exemplified in this book. The book opens with a tour of the forces in practice and science that have shaped the scholarship of nursing. Fitzpatrick’s introduction gives us a dynamic account of how our distinct disciplinary knowledge has evolved and what the key elements of its substance and structure are. Quinn Griffin and Landers’s overview of foundational conceptual structures (self-care, adaptation, unitary human beings, human ­caring) reminds us where nursing’s theoretical roots began and how they are evolving through middle range theories to clarify distinct focuses of nursing. The core of the book is composed of 22 chapters divided into four parts to distinguish completed and ongoing or planned research. The contributing authors elaborate on a wide variety of theories. They bring focused knowledge and clinical expertise in applying theory to research to explain patients’ health-related experiences and behaviors, and to propose interventions. Examples from the second part include theories on facilitating older people’s transition from hospital to home; symptom management following rectal cancer surgery; lowering environmental stress to support Alzheimer’s

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Foreword

patients; and theories of cultural competence and work engagement to improve nursing care. The third part demonstrates the diversity of practice problems that can be addressed by nursing theory–based research with examples using Story Theory to improve communication for nurse leaders and managers in complex work situations; Human Caring Theory to understand nurse–patient interactions in the emergency department; Self-Transcendence Theory to develop computer-­mediated self-help practices; and Theory of Meaning to study patient loss in pregnancy and chronic illness. Several chapters illustrate how nurses glean important theoretical resources from other disciplines’ history of theories, such as Frankl’s 1959 Theory of Meaning, Kanter’s 1977 Structural Empowerment Theory, Cassel’s 1976 Social Support Theory, Burns’s 1978 Transformational Leadership Theory, Berry’s 1980 Acculturation Theory, Leventhal’s 1980 Self-Regulation Model, and Ajzen’s 1985 Theory of Planned Behavior. Systematically evaluating theories, particularly those originating from the theoretical perspectives and goals of other disciplines, is both logical and ethical in developing nursing knowledge. It helps ensure that theory meets standards of care as well as criteria of science. The authors elaborate on this and other evaluative processes, and summarize their findings in a useful table in each chapter. Chapters are uniquely informative because authors discuss their ideas, rationale, and approaches in developing neotheories and frameworks. For example, C ­ offey’s framework was devised from Meleis’s Transitions Theory to guide research on the readiness of older people at discharge to move from acute hospital care to home; Cleary, Burton, and Hegarty used Wood’s holistic perspective of sexuality to construct a conceptual framework to study people at risk of altered sexuality from illness; and Heffernan and O’Mahony each employed multiple theories to develop their research-guiding frameworks. These illustrations of theorizing are especially relevant because the problems of concern to nurses may not fit into a preexisting theory. Students struggling to find that one perfect theory may better spend their time modifying an existing theory or creating one of their own. This book enables nurses to formulate theories for research that are meaningful to their practice and patients. Another strength of the book is the authors’ attention to historical as well as contemporary literature on the theories. Students will appreciate having information at hand regarding the origins of concepts and classic theories—Social Support, Self-Regulation, Symptom Management, Acculturation, Empowerment, Work Engagement, and Interpersonal Relations—often used as frameworks for research or practice, or as foundations for developing theories. The book concludes with a thought-provoking chapter on theory applications that inform and guide nursing interventions. This represents another step forward, one that is particularly relevant to nursing practice at all levels. Knowledge development pivots around theory. The chapters show what nurses can do with theory, creatively yet systematically applied across all phases of research and translated for use in practice. There is something here for all students of nursing knowledge. This innovative book will inform and inspire readers to decisively engage theories in building nursing knowledge for research and practice. Pamela G. Reed, PhD, RN, FAAN Professor The University of Arizona College of Nursing Tucson, Arizona

Preface

The idea for this book arose as a result of teaching theory courses/modules in the United States and Ireland. The course outcomes necessitated that students identified a theory to support their research. At times, delineation of theoretical perspectives became challenging for both the students and the instructors. Nursing as a discipline is relatively young and the theoretical development of nursing knowledge is even more recent. The unique nature of this book is in the full explication of the process of using theory to guide research and professional practice. It had become apparent for some time that a book was not available that presented theories underpinning research, and their use in either research or practice. Doctoral students are challenged to base their research on theories and this text provides key examples of how this has been accomplished. Currently, there are several books on specific grand and middle range theories in nursing, and a few books that include a collection of analysis and application of specific middle range theories in nursing. Yet there are no other books that take the reader through the process of the use of a theory to guide one’s research, from inception of the research question to evaluation of future research. This book provides the template that will be most useful to future students of nursing’s disciplinary knowledge development. The book is structured in four parts; two of these parts are specific examples of theories applied to research conducted or future research and practice. Each of these 18 chapters follows a structured format such that comparisons across theories can be more easily made. The components of each chapter are: basic description of the theory, core concepts, research from other disciplines related to the theory, relationship of the theory to nursing metaparadigm concepts, theory analysis, relationship of the theory to prior research in nursing, use of the theory in this research, and recommendations for further research. These selected theories allowed authors to operationalize concepts in an exciting and innovative manner. The theory analysis section is particularly useful in that each chapter follows the same format for that section. Each chapter includes figures and tables that further explain the complex relationships between and among concepts embedded in the theories.

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Preface

The book will be useful to doctoral students and their instructors, as well as to new and experienced nurse researchers. Also, many journal editors are currently seeking manuscripts that include the theoretical basis for the research. This text provides examples of how one moves from theoretical to empirical knowledge development. We expect that it will enhance dialogue between and among researchers and graduate students in nursing programs globally. Joyce J. Fitzpatrick Geraldine McCarthy

Acknowledgments

We acknowledge all of the nurses, past and present, exploring, explaining, and eventually integrating theoretical thinking into their scholarship. In particular, we wish to acknowledge the nurse scholars who contributed to this book. We look forward to continued advancement of our theoretical thinking through ongoing dialogue with them.

Share Theories Guiding Nursing Research and Practice

part i

Introduction

chapter 1

The Discipline of Nursing Joyce J. Fitzpatrick

What is a discipline? Is nursing a distinct discipline? If yes, what is the distinct knowledge base that characterizes the discipline of nursing? These questions have been addressed throughout the nursing literature, most thoroughly since the 1970s, as nursing advanced within the university settings, as schools for university prepared nurses, and research doctoral programs in nursing were expanded. Nurse leaders had carved out their role in academe, and there was a concomitant need to describe and define the discipline of nursing to provide legitimacy within the academy. A discipline is a branch of knowledge with a distinct set of rules of conduct for developing that knowledge and methods of practice for expanding the knowledge. And so it was that nurse leaders began an exploration of the discipline of nursing, using a range of means for debate, delineation, description, and refinement. But in retrospect, we now trace these disciplinary longings to the founder of modern nursing, Florence Nightingale, who is often acknowledged by contemporary nurse scholars as a preeminent nurse theorist. As such, Nightingale set the stage for further development of the discipline of nursing, with its own boundaries and rules of conduct for its scientific deliberations and professional practice. Nightingale’s theoretical works are referred to as the “laws of health” and as an environmental theory. In 1859 Nightingale wrote Notes on Nursing (1860), a book that created the foundation for the profession of nursing and the curricula at the Nightingale School as well as other nursing schools. Throughout her work, Nightingale emphasized the importance of knowledge for the practicing nurse. Nightingale postulated that knowledge of health laws (expertise that she considered nursing) would aid the nurse in putting a person in a state so that there would be no disease, or so that the person could recover from disease. She believed that this basic knowledge should assume a high place in the overall understanding of health and illness. For Nightingale, the environment was a key concept because she placed much emphasis on putting the patient in the best environment in order to stay healthy or to regain health. Nightingale instructed nurses to provide fresh air, pure water, sufficient food, light (particularly direct sunlight), and sanitary living conditions. She believed that nurses should focus on altering the environment so that the patient’s body could heal itself.

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Part I  Introduction

Aside from the writings of Nightingale (now considered theoretical contributions), theory development literature in nursing is relatively recent, more recent than the development of nursing research. In the 1960s and early 1970s in the United States, a national debate was occurring about the nature of, and the need for, nursing theory to firmly establish the nursing discipline as an academic department—one that warranted the future development of PhD programs in nursing. Questions were raised by nursing leaders that were very basic to the understanding of the disciplinary context, such as the nature of nursing, the nature of nursing theory and research, and the nature of the profession, the practice of nursing. National nursing theory conferences were held—forums in which leaders expressed views about both the process and the content that should characterize the nursing discipline—with specific attention to the theoretical dimension of scientific development of nursing (Norris, 1969–1970). Schlotfeldt and Rogers, two national nursing leaders of the time, were key movers in the educational reform in nursing, even though they proposed different means for advancing nursing knowledge. Their works substantially influenced nursing education. Schlotfeldt became the architect of the first professional doctorate in nursing, established at Case Western Reserve University in 1979 (Scholtfeldt, 1978). In designing this new educational approach, modeled after professional doctorates in other health disciplines (MD and DDS programs), Scholtfeldt was ahead of her time. She firmly believed that there was something to know in nursing and that through continued knowledge development nurses could make significant contributions to an exemplary health care system. Further, she believed that this was the way for nursing to emerge as a full-fledged profession (Schlotfeldt, 1978, 1988). Whereas Schlotfeldt focused on the entry level of nursing education, Rogers placed her energies on PhDlevel nursing education, developing the largest and most prestigious PhD program in nursing at the time. This New York University PhD in nursing program was focused almost exclusively on the development of nursing science, particularly theory and research that emanated from the Science of Unitary Human Beings, the conceptualization developed by Rogers (1970). Rogers’s strategy for influencing the disciplinary development was to recruit and prepare large numbers of nurse scholars. Several of the Rogerian scholars contributed significantly to the ongoing deliberations of nursing science as basic science (e.g., Barrett, Cowling, Fawcett, Fitzpatrick, Fry, ­Malinski, Newman, and Smith). Another distinction between Scholtfeldt and Rogers was their views on the nature of the discipline; Rogers considered nursing a basic science, whereas Schlotfeldt viewed nursing as an applied science, one more closely modeled after medical science. One of the classic papers of the time that led to considerable debate at the first National Theory Conference was the seminal work of the nurse philosopher Rosemary Ellis (1968), “Characteristics of Significant Theories,” in which she raised the issues of theories for nursing, theories of nursing, or nursing theories, crystalizing the elements of a debate that centered on questions of the nature of science in nursing— basic or applied. Ellis believed in the combination of applied and basic knowledge in nursing, with more emphasis on the applied dimension of knowledge development. According to Ellis, nursing knowledge should be obtained through various means, and she identified four different types of information for nursing inquiry: scientific knowledge (e.g., biology and anatomy), historical knowledge (the context of illness and the difference between disease and wellness), nursing philosophy (ethics and empathy), and nursing technology (apparatuses and their effectiveness). Scientific research provided a way for the nurse to draw upon fields such as anatomy and



Chapter 1  The Discipline of Nursing

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biology to understand the internal physiological processes within the patient. Historical study enabled the nurse to understand the context of illness and its treatment, such as the distinction between a disease and a health-based approach to wellness. Philosophical exploration humanized the nurse through the study of ethics and taught empathy in patient care. Finally, technological investigation included studies of various nursing apparatuses and how effective they were in interactions with the patient. Nursing as basic science would require PhD programs in the discipline, creating disciplinary knowledge that had a distinctive focus (to other “ologies” on academic campuses, such as biology, psychology, sociology, etc.). During this period of debate regarding the nature of the scientific discipline, there were proposals for naming the science of nursing nursology. Nurse theorists Paterson and Zderad, developers of a theory called Humanistic Nursing (1976), are often credited with introducing this recommendation. In the introduction to their book outlining their theory, these authors describe their conceptual developments and challenges in a manner that might be used to describe a theory class in doctoral programs today. In the preface to their first edition, Paterson and Zderad describe their work and their conceptual ideas about the nature of nursing theory development. Through dialogue and reflection they were able to consolidate their thinking about nursing theory as Humanistic Nursing (Paterson & Zderad, 1976, p. 1). The term nursology also appeared in the European nursing literature in the mid1970s. Roper, a nurse theorist from Scotland, argued for the development of a science of nursing labeled nursology, so that nursing as a discipline might best describe its characteristic mode of thinking. She asserted that this label would help the scientific nursing community to think nursologically, thus distinguishing between the practice of nursing, the professional doing of the work of nursing, and the science of nursing, or the study of nursing practice (Roper, 1976). Although the labeling of the science of nursing as nursology did not receive support from the wider academic nursing community, remnants of this minor movement appear today. Students in current doctoral-level nursing theory classes often express interest in the term as a way to legitimize the scientific enterprise and distinguish nursing science from other disciplines, particularly health disciplines. A definition of nursology appears in the current literature as follows: Nursology: a conceptual framework for the study and practice of nursing. It requires the nurse to interact with the patient in an “authentic” way, . . . the nurse must take the risk of caring. . . . Nursology is intended to provide a model for nursing methods and research . . . and the science of nursing may emerge. . . . (Mosby’s Medical Dictionary, 2009) In contrast to understandings of nursing as basic science, nursing as applied science would be similar to medicine, in which professional practitioners studied for the PhDs in related disciplines and applied that knowledge to the understanding of diseases, as well as their treatment and cure. This view provided both conceptual and practical support for the Nurse Scientist movement. As a result of the intellectual turmoil among the nurse leaders, the debates about the best way forward for development of disciplinary knowledge, and the paucity of nurses prepared with doctorates in nursing, knowledge development in the mid-1970s—during the rapid expansion of research doctoral programs in nursing—often underscored the applied

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Part I  Introduction

science dimension. Nurse researchers who were prepared as psychologists, sociologists, and anthropologists applied theories from these disciplines to clinical problems in nursing. Often, this application of knowledge was devoid of reformulation of the data from a nursing philosophical perspective. Thus, much of this early research in nursing enhanced theory development in other disciplines while adding considerable knowledge to guide the professional practice of nursing. Additional concerted focus on nursing theory development can be directly traced to the expansion of research doctoral programs in nursing, first in the United States in the mid-1970s and more recently globally, including in Europe and Asia in particular. In the post–World War II period, when university programs to prepare nurses were expanding, most nurse faculty received their doctoral preparation in other related disciplines, such as psychology, sociology, anthropology, physiology, and, most often, education. There was even federal support through the Nurse Scientist Program to prepare nurses with doctorates in other related disciplines. Many leaders in nursing were products of the Nurse Scientist Program. They were thus socialized into these related disciplines, adopting (and at times adapting) the theoretical knowledge and the research methods to nursing research and scholarly inquiry. Prior to 1975 there were only seven nursing doctoral programs in the United States; three of these were PhD programs, one granted a doctorate in nursing education (an EdD), and the other three were doctor of nursing science programs. According to Risjord (2010), a philosopher who has studied the nursing discipline, three seminal works appeared in 1978 that crystallized the nature of nursing as basic science. In their classic paper “The Discipline of Nursing,” Donaldson and Crowley (1978) distinguished nursing as a professional discipline, with a value orientation that required theoretical guidance for the professional practice of nursing. Further, they described three disciplinary themes for the development of nursing knowledge: 1. Concern with the principles and laws that govern the life processes, well-being, and optimal functioning of human beings—sick or well. 2. Concern with the patterning of human behavior in interaction with the environment in critical life situations. 3. Concern with the processes by which positive changes in health status are affected (p. 113). Carper (1978) described four fundamental patterns of knowing in nursing: empirics, ethics, esthetics, and personal knowing. Carper isolated scientific knowledge in the empiric way of knowing and argued that there was a distinction between scientific knowledge and knowing what to do (professional practice). Fawcett (1978), in describing the double helix of nursing science, detailed the necessary relationship between theory and research, viewing these two components as intertwined. Whereas this perspective is often interpreted as necessitating a deductive approach to science development, other methods of developing science could be included. There are compelling arguments in the literature for using other theory development approaches (e.g., grounded theory), or for developing theory and research from questions generated through clinical practice. Yet, as the debates continued, those who were prepared in other more established disciplines outnumbered those prepared in nursing science. Those with PhD degrees



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in nursing, particularly those with an emphasis on nursing science and nursing theory, were in the minority. Although there was demand for their expertise in new PhD programs in nursing, these scientists were often marginalized within the scientific nursing community. And, as other minorities often do, they formed their own groups; however, these groups were often perceived by the dominant group as fringe organizations. Margaret Newman, a prominent nurse theorist who taught nursing theory to many doctoral students at New York University, initiated a Nursing Theory Think Tank, which held its first meeting at Pennsylvania State University in 1978. This informal group met once a year, for more than a decade, to discuss and debate current issues in development of disciplinary nursing knowledge. Participants included leading authors of nursing theory papers and books (e.g., Kay Avant, Barbara Carper, Peggy Chinn, ­Rosemary Ellis, Jacqueline Fawcett, Joyce Fitzpatrick, Margaret Hardy, Rosemarie Parse, Callista Roy, Lorraine Walker, and Ann Whall). Although no formal record of the work of this organization appears in the literature, its existence is an important factor in the history of nursing knowledge development. These were the thought leaders in nursing theory development and their subsequent publications regarding nursing theory provide testament to their leadership (e.g., Carper, 1978; Chinn & Kramer, 1983; Ellis, 1982; F ­ awcett, 1980, 1984; Fitzpatrick & Whall, 1983; Walker & Avant, 1983).

Linking Nursing Theory and Nursing Research There is considerable literature on the need for, and nature of, nursing research. The history of nursing research can be traced to the mid-1940s, when it was supported at the federal level through the Division of Nursing within the Office of the Surgeon General, Public Health Service. In 1955, the first extramural research funding was provided through the Division of Nursing (NINR, 2013a). Yet, throughout the next several decades, growth in nursing research was painfully slow. According to the NINR 25th-anniversary history report, there were approximately 4,000 nurses with doctoral degrees in 1980 and more than half of them held PhDs, yet only 6% reported their primary function as research. There had been limited funding for nursing research and most of the scientific community, including NIH (National Institutes of Health), did not understand or appreciate nursing research (NINR, 2010). The fact that the nursing community in the 1980s was divided on the definition of nursing research contributed to the biomedical community’s lack of understanding. The year 1985 marked the formal establishment of the National Center for Nursing Research (NCNR) at the NIH. In 1993, the NCNR was elevated to an institute at NIH and renamed the National Institute of Nursing Research (NINR). The impetus for establishing NINR came from the findings of two federal studies: (a) a 1983 report by the Institute of Medicine (IOM) recommended that nursing research should be included in the mainstream of biomedical and behavioral science; and (b) a 1984 NIH Task Force study found nursing research activities to be relevant to the NIH mission (NINR, 2013a). Nursing research often was not connected directly to nursing theory, and the value of nursing theory was not always recognized. It can be interpreted that the 1983 IOM report, in characterizing nursing research as part of biomedical and/or behavioral science, implied that nursing was an applied science. There is mention only of one aspect of science, that of research, without the concomitant focusing on nursing science as an entity (i.e., as including both nursing theory and research).

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Part I  Introduction

The 2011 NINR mission statement includes attention to both basic and applied (i.e., clinical) research and is as follows: “…to promote and improve the health of individuals, families, communities, and populations.” The institute supports and conducts clinical and basic research and research training on health and illness across the life span to build the scientific foundation for clinical practice, prevent disease and disability, manage and eliminate symptoms caused by illness, and improve palliative and end-of-life care (NINR, 2013b). Because of its positioning within the NIH, an institution that has a firm commitment to biomedical research, particularly quantitative biomedical research, and because of the value for extramural research funding, the scientific emphasis in nursing has been consistent with the dominant paradigm of NIH.

The Basic Structure of Nursing Knowledge Throughout the nursing knowledge literature there is general agreement that nursing knowledge has developed from the abstract to the specific, from the broad theoretical propositional statements to the specific testable hypotheses. Nursing science has thus included several levels: the philosophical positions within the discipline (including the ethics and values statements defining nursing moral positions); the conceptual models (or grand theories) of nursing, sometimes also referred to as conceptual frameworks; the middle range theories, derived from conceptual models of nursing or from theories from other disciplines, reformulated within nursing’s philosophical view; and situation-specific theories that have been generated to explain a particular occurrence or phenomenon. Conceptual models of nursing were generated early in the efforts to define the discipline, yet received widespread dissemination in the latter half of the 1970s through the 1990s. Students at all levels of university-based education, from the baccalaureate to the doctoral level, were introduced to nursing theory primarily through these grand theories. However, with the translation of the theories to professional practice not yet having occurred, a subsequent theory–practice gap was noted. Students were not always aware of the relevance of the theories, and the theorists were not always eager to translate their scholarship in ways meaningful to the clinicians. Critiques of this theory–practice gap were found in the literature, and often the debates centered around the type of research that was being used to test the theories, namely the emphasis on the scientific method of logical positivism. Shortly after the widespread adoption of the nursing conceptual models in nursing education, a number of nurse scholars published books that included comparisons of these models (Alligood, 1986; Fawcett, 1984; Fitzpatrick & Whall, 1983; George, 1980; Parker, 1990). Whereas different models for theory analysis and evaluation were used across the publications, there also was some consistency in inclusion of the following dimensions: basic concepts included in the theories/models, relationships among the core concepts as outlined by the theorist, and the internal (e.g., parsimony, logical consistency) and external (e.g., significance, usefulness in research, education and practice) validity of the theory. Components of theory analysis and evaluation that had first been introduced to nursing by Hardy (1974) have most often served as the structure for these evaluations. In the mid-1980s, theorists such as Watson (1985) and Benner (1984) developed knowledge models designed to address this theory–practice gap. Each was interested in describing the doing of nursing. Watson provided insights on the caring



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role of nurses, and Benner delineated the development of the professional practice role in her novice-to-expert description of how nurses gain expertise as they gain clinical knowledge. Both of these perspectives have received much attention in the clinical practice arena, particularly among nurses practicing in acute care settings. More recent derivations of Watson’s focus on caring include Swanson’s (1991) middle range caring theory and the model of Relationship-Based Care (Koloroutis et al., 2004) that is used in several major hospitals as a professional practice model. Another attempt to close the theory–practice gap was the deliberate development of middle range theory. Although there had been several middle range theories derived from the more abstract conceptual models of nursing, attention to middle range theory development was highlighted in 2003 with the publication of two collections of developed and developing middle range nursing theories (Peterson & Bredow, 2003; Smith & Liehr, 2003). This attention to middle range theory development was consistent with the expansion of nursing research developments. In addition, students in professional doctoral programs are expected to apply theory to the practice. These middle range theories have been translated into practice, often by the theorists themselves, but also by others who have studied the theory. Thus, there is evidence of their relevance to practice and use by both researchers and expert practitioners. For example, Reed’s (2003) middle range theory of self-transcendence has been applied in a number of practice settings and patient groups (e.g., Hunnibell, Reed, Quinn Griffin, & Fitzpatrick, 2008; Palmer, Quinn Griffin, Reed, & F ­ itzpatrick, 2010; Ramer, Johnson, Chan, & Barrett, 2006; Reed, 2009; S ­ harpnack, Quinn Griffin, Bender, & Fitzpatrick, 2011; Thomas, Burton, Quinn Griffin, & ­Fitzpatrick, 2010). Several middle range theory applications from nursing theories as well as from theories derived within related disciplines are included in subsequent chapters in this book. Another development that was focused on bridging the theory–practice gap has been the emphasis on situation-specific theories. Im and Meleis (1999) described this approach to theory development as a way to link theory to both practice and research. Situation-specific theories are characterized by a low level of abstraction, are related to specific nursing phenomena, are contextualized (e.g., within the specific environment of care or within a certain country), and therefore have limited generalizability. More recently, Meleis has provided several situation-specific theories related to the middle range theory of transitions (Meleis, 2010). Included are transitions that are based on developmental stages and situational transitions such as discharge, relocation, immigration, and education.

Where Are We Now? Middle range theories now serve as the core focus for graduate-level nursing theory courses. Both the Peterson and Bredow (2012) and the Smith and Liehr (2013) books have recently appeared in their third editions; both collections have added new middle range theories over the years since the first edition publications. Also, several nursing theories in use today have been derived from knowl­ edge originally developed by scholars from other disciplines. Examples of these include Roy’s (1976) Adaptation Model derived from understandings of stress, and adaptation derived primarily from physiology, Leininger’s (1978) transcultural nursing model derived from anthropology; Pender’s (1997) model of health

10

Part I  Introduction

promotion and Resnick’s (2003) middle range nursing Theory of Self-Efficacy derived from the social psychological self-efficacy theory; and Meleis’s (2010) transitions theory came from the sociological theory of role supplementation. It is important to note that although these theories from other disciplines were originally borrowed, they have been reformulated from the nursing perspective and applied to research, education, and professional practice within the nursing discipline. At times, the basic concepts are used in combination with other concepts more directly related to nursing knowledge and the nursing metaparadigm. There are several other examples in the nursing literature of research based on theories from other disciplines. At times these theories have been applied to nursing phenomena without theoretical reformulation. An example of research in nursing using theories from other disciplines includes that based on the stress and coping model of Lazarus and Folkman (1984).

THE WAy FORWARD The number of doctoral programs in nursing has greatly expanded in the past decade, particularly with the introduction of the professional doctorate. In the United States there are now 111 research-based doctoral programs (PhD programs) and 153 professional doctoral programs (Doctor of Nursing Practice [DNP] programs) (American Association of Colleges of Nursing, 2013). There also are a few new doctoral programs in nursing that award the EdD degree, and thus focus on the preparation of nurse educators. This overall doctoral program expansion is mirrored globally; as demand for nurse scientists and faculty grows, doctoral programs are expected to continue to expand. In 2010 in the United States, approximately 1,669 students graduated from nursing doctoral degree programs; this represents approximately 0.9% of graduates in the field graduating at the doctoral level. The number of graduates has grown over the past 4 years, almost exclusively due to the expansion of professional doctoral (DNP) programs. In 2006, 414 doctoral degrees in nursing were earned. Thus, the number of program graduates has increased by an estimated 303% from 2006 to 2010 (Education Index, 2013). In other countries, such as Ireland, the professional doctorate that has been developed, the Doctor of Nursing (DN) degree program, is considered a research degree, much like the PhD in nursing in Ireland, but with a taught component. Thus, this preparation will contribute to the need for both nurse scientists and nurse faculty. In the United States there is much diversity among DNP programs; some of the existing programs have a strong research emphasis and others are exclusively focused on preparation of advanced nurse practitioners. Yet, even with the emphasis on advanced practice, there is attention to the need for theory-based practice within the curricula in DNP programs. For example, many expert nurse clinicians are interested in theories of health behavior change, including those theories from nursing such as the health promotion theory of Pender (1997) or the stages of change model of Prochaska and DiClemente (1984) reformulated to consistency with the nursing metaparadigm. There also is diversity in the nature and quality of doctoral education in nursing within PhD degree programs. A wide range of topics are included in programs of research among faculty, and thus among their students. Hence, as in other disciplines, it is not only the degree that matters, but also the content of the preparation.



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Importantly, there is increased inclusion of nursing knowledge development, both theory and research, at all levels of graduate nursing education. Doctoral students in nursing are eager to advance the disciplinary knowledge and contribute insights that guide professional practice. The scientific content of their scholarly deliberations are most often embedded in the early descriptions of nursing as basic science, most notably consistent with the themes identified by Donaldson and Crowley (1978), although not losing sight of the need for other ways of knowing as practicing professionals. In particular, the discipline has experienced an increased emphasis on understanding the ethics that undergird health care delivery and practice. Topics such as health care disparities, moral distress, and ethical decision making among professionals faced with complex questions in end-of-life care are among those that have received considerable attention by nurse scholars. And it is significant to note that the value for science development has been enhanced throughout the discipline. This value augurs well for the future of nursing. Nurse scholars continue to develop theoretical, empirical, and expert clinical knowledge for the nursing discipline. Throughout this journey it is important to consider the model of scholarship proposed by Boyer (1990) who challenged all disciplines to fully embrace four key areas of scholarship in their academic work: the scholarship of discovery (the generation of new and unique knowledge through theory development and research); the scholarship of teaching; the scholarship of application (to societal issues or, in the case of nursing, to the clinical issues in health care); and the scholarship of integration (crossing disciplinary boundaries) (Boyer, 1990). In 1999, the American Association of Colleges of Nursing (AACN) provided numerous examples of how each of these components of scholarship could be actualized within the discipline of nursing. Key to the AACN delineation of standards of the scholarship of discovery was inclusion of the process of theory development along with research development (including empirical and historical research, methodological studies, and philosophical inquiry). This value of theory development also augurs well for the future.

References Alligood, M. R. (1986). Nurse theorists and their work. St. Louis, MO: Mosby. American Association of Colleges of Nursing. (1999). Defining scholarship for the d­ iscipline of nursing. Retrieved from http://www.aacn.nche.edu/publications/position/definingscholarship American Association of Colleges of Nursing. (2013). Institutions offering doctoral programs in ­nursing and degrees conferred. Retrieved from http://www.aacn.nche.edu Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison-Wesley. Boyer, E. (1990). Scholarship reconsidered: Priorities for the professoriate. Princeton, NJ: The Carnegie Foundation for the Advancement of Teaching. Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–23. Chinn, P. L., & Kramer, M. K. (1983). Integrated theory and knowledge development in nursing. St. Louis, MO: Mosby. Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26(2), 113–120.

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Part I  Introduction Education Index. (2013). The best doctoral degree in nursing programs: Rankings table and ­overview. Retrieved from http://graduate-school.phds.org/education-index/phd-innursing-programs Ellis, R. (1968). Characteristics of significant theories. Nursing Research, 17(3), 217–222. Ellis, R. (1982). Conceptual issues in nursing. Nursing Outlook, 30(7), 406–410. Fawcett, J. (1978). The relationship between theory and research: A double helix. Advances in Nursing Science, 1(1), 36–39. Fawcett, J. (1980). A framework for analysis and evaluation of conceptual models of nursing. Nurse Educator, 5(6), 10–14. Fawcett, J. (1984). Analysis and evaluation of conceptual models of nursing. Philadelphia, PA: F. A. Davis. Fitzpatrick, J. J., & Whall, A. L. (1983). Conceptual models of nursing: Analysis and evaluation. Englewood Cliffs, NJ: Prentice Hall. George, J. (Ed.). (1980). Nursing theories: The base for professional practice. Norwalk, CT: Appleton & Lange. Hardy, M. (1974). Theories: Components, development, evaluation. Nursing Research, 23(2), 100–107. Hunnibell, L. S., Reed, P. G., Quinn Griffin, M. T., & Fitzpatrick, J. J. (2008). Self-transcendence and burnout in hospice and oncology nurses. Journal of Hospice and Palliative Nursing, 10(3), 172–179. Im, E. O., & Meleis, A. I. (1999). Situation-specific theories: Philosophical roots, properties, and approach. Advances in Nursing Science, 22(2), 11–24. Koloroutis, M., Manthey, M., Felgen, J., Person, C., Kinnaird, L., Wright, D., & Dingman, S. (2004). Relationship based care: A model for transforming practice. Minneapolis, MN: Creative Health Care Management. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer Publishing Company. Leininger, M. M. (1978). Transcultural nursing: Concepts, theories and practices. New York, NY: Wiley. Meleis, A. I. (2010). Transitions theory: Middle range and situation specific theories in nursing research and practice. New York, NY: Springer Publishing Company. Mosby’s Medical Dictionary. (2009). New York, NY: Elsevier. National Institute of Nursing Research. (2010). NINR: Bringing science to life. Bethesda, MD: National Institutes of Health. National Institute of Nursing Research. (2013a). History. Retrieved from http://www.ninr.nih. gov/aboutninr National Institute of Nursing Research. (2013b). Mission & strategic plan. Retrieved from http:// www.ninr.nih.gov/aboutninr Nightingale, F. (1860/1969). Notes on nursing: What it is and what it is not. New York, NY: Dover. Norris, C. M. (1969–1970). 1st–3rd Proceedings Nursing Theory Conference. Kansas City: University of Kansas Medical Center Department of Nursing Education. Palmer, B., Quinn Griffin, M. T., Reed, P., & Fitzpatrick, J. J. (2010). Self-transcendence and work engagement in acute care staff registered nurses. Critical Care Nursing Quarterly, 33(2), 138–147. Parker, M. E. (1990). Nursing theories in practice. New York, NY: National League for Nursing. Paterson, J. G., & Zderad, L. T. (1976). Humanistic nursing. New York, NY: National League for Nursing.



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Pender, N. J. (1997). Health promotion: An emerging science for self-care and professional care. Qualitative Nursing, 3(5), 449–454. Peterson, S. J., & Bredow, T. S. (2003). Middle range theories: Application to nursing research. Philadelphia, PA: Lippincott Williams & Wilkins. Peterson, S. J., & Bredow, T. S. (2012). Middle range theories: Application to nursing research (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Toward a systematic eclectic framework. Homewood, IL: Dow Jones Irwin. Ramer, L., Johnson, D., Chan, L. & Barrett, M. T. (2006). The effect of HIV/AIDS disease progression on spirituality and self-transcendence in a multicultural population. Journal of Transcultural Nursing, 17, 280–289. doi:10.1177/1043659606288373 Reed, P. G. (2003). Theory of self-transcendence. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing (pp. 105–130). New York, NY: Springer Publishing Company. Reed, P. G. (2009). Demystifying self-transcendence for mental health nursing practice and research. Archives of Psychiatric Nursing, 23(5), 397–400. Resnick, B. (2003). Theory of Self-Efficacy. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing, (pp. 197–224). New York, NY: Springer Publishing Company. Risjord, M. (2010). Nursing knowledge: Science, practice, and philosophy. West Sussex, England: Wiley-Blackwell. Rogers, M. E. (1970). An introduction to the theoretical basis of nursing. Philadelphia, PA: F. A. Davis. Roper, N. (1976). A model for nursing and nursology. Journal of Advanced Nursing, 1, 219–227. Roy, S. C. (1976). Introduction to nursing: An Adaptation Model. Englewood Cliffs, NJ: Prentice Hall. Schlotfeldt, R. M. (1978). The professional doctorate: Rationale and characteristics. Nursing Outlook, 26(5), 302–311. Schlotfeldt, R. M. (1988). Structuring nursing knowledge: A priority for creating nursing’s future. Nursing Science Quarterly, 1(1), 35. Sharpnack, P. A., Quinn Griffin, M. T., Bender, A., & Fitzpatrick, J. J. (2011). Self-transcendence and spiritual well-being in the Amish. Journal of Holistic Nursing, 29(2), 91–97. Smith, M. J., & Liehr, P. R. (2003). Middle range theory for nursing. New York, NY: Springer Publishing Company. Smith, M. J., & Liehr, P. R. (2013). Middle range theory for nursing (3rd ed.). New York, NY: Springer Publishing Company. Swanson, K. M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161–166. Thomas, J., Burton, M., Quinn Griffin, M. T., & Fitzpatrick, J. J. (2010). Self-transcendence and spiritual well-being among women with breast cancer. Journal of Holistic Nursing, 28(2), 115–122. Walker, L. O., & Avant, K. C. (1983). Strategies for theory construction in nursing. Englewood Cliffs, NJ: Prentice Hall. Watson, J. (1985). Nursing: Human science and human care: A theory of nursing. Norwalk, CT: Appleton-Century-Crofts.

chapter 2

Extant Nursing Models and Theories: Grand and Middle Range Theories in Nursing Mary T. Quinn Griffin and Margaret G. Landers

Theory provides a framework to explain phenomena of relevance to nursing at both an abstract and concrete level. Theories can differ in terms of their level of abstraction and scope/applicability. The more abstract and broader the category of theory is, the wider its scope. Theories that are less concrete and explicit are referred to as grand theories. Conversely, the narrower the scope of the theory, the more applicable it is to practice. This type of theory is defined as a middle range theory (Fawcett, 2005). Grand theories provide global understandings of the nature of nursing knowledge and set the boundaries for disciplinary knowledge development in nursing. The grand theories described in this chapter are the Adaptation Model (Roy), the Self-Care Deficit Theory of Nursing (Orem), the Theory of Human Caring (Watson), and the Science of Unitary Human Beings (Rogers). This overview is followed by a review of seven middle range theories: The Theory of Meaning (Starck), the Theory of Uncertainty in Illness (Mishel and Clayton), the Theory of Unpleasant Symptoms (Lenz, Pugh, Milligan, Gift, and Suppe), the Theory of Comfort (Kolcaba), the Theory of Self-Efficacy (Resnick), the Theory of Nursing Intellectual Capital (Covell), and the Theory of Peaceful End of Life (Ruland and Moore).

GRAND THEORIES Adaptation Model Callista Roy first published the Adaptation Model in 1970 (Roy, 1970). Her work was influenced by her clinical background in pediatric nursing. From a theoretical perspective, Roy drew on the tenets of Harry Helson’s theoretical assertions based on psychophysical principles (Roy, 1984). Helson (1964) described adaptive responses as an integral part of the incoming stimulus and its effects. In addition, Roy was influenced by the work of Von Bertalanffy (1968) and Rapoport (Roy & Roberts, 1981), and from a nursing perspective by Johnson’s Model for Behavioral Systems (Johnson, 1980).

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Adaptation is the core concept in Roy’s theory. The theory is based on the premise that adaption is the desired outcome for coping, development, and growth for optimum quality of life and death with dignity. According to Roy (1980), a patient’s response to a stimulus can either be adaptive (or healthy) or nonadaptive. People’s inability to adapt arises when they fail to manage or respond to internal or external environmental stimuli. However, the response is not passive; rather, it is dependent on a person’s coping mechanisms—both cognitive and psychological. Roy described self-concept and group identity modes also. The latter is made up of the combined influence of three classes of stimuli: focal stimuli, contextual stimuli, and residual stimuli. According to Roy (1980), a focal stimulus is the main problem that challenges a person’s ability to adapt. The problem can be either internal or external. The contextual stimuli (e.g., environmental factors) have a direct influence on the focal stimuli. Residual stimuli are additional stimuli that can be internal or external. However, these do not have any noticeable effect on a person. Roy outlined four adaptive processes or adaptive modes (Roy, 1980): physiological mode, self-concept mode (focuses on psychological and spiritual responses), interdependence mode (associated with close relationships), and the role function of the person. In nursing, mutual goals between the patient and nurse are set and evaluated to determine if interventions are successful. The metaparadigm concepts discussed within the context of the Adaptation Theory are person, health, environment, and nursing. Relating to the first concept, person, it is Roy’s contention that people are holistic adaptive systems and that they are the main focus of nursing (Roy, 1980). Humans have cognitive and emotional capabilities. Hence, they are able to adjust to and effect change. Health is defined as more than the absence of disease and illness, and as a process of becoming integrated as a whole person (Roy, 1980). The environment is considered in the context of all the conditions that impact on the development and behavior of individuals and groups including their ability to adapt.

Self-Care Deficit Theory of Nursing Dorothea Orem first conceptualized the self-care model of nursing in the latter half of the 1950s. Orem (1971) defines self-care “as the practice of activities that personally initiate and perform on their own behalf in maintaining life, health and well-being” (p. 13). Orem was the first nurse theorist to adopt the term self-care. Self-care is associated with the activities or behaviors that patients engage in to promote health and minimize self-care deficits (Orem, 1971). A central aim of the self-care theory is to understand the reasons why patients seek nursing care (Orem, 1971, 1995, 2001). The overall theory developed by Orem is called the Self-Care Deficit Theory of Nursing, which is a composite of three related subtheories centered on the concept of self-care (Orem, 1971, 1995, 2001): the Theory of Self-Care, the Self-Care Deficit Theory, and the Theory of Nursing Systems. The concept of self-care and related concepts are presented in the context of the three subtheories: the Theory of Self-Care that provides an explanation of the concept self-care; the Self-Care Deficit Theory that explains how patients need nursing during ill-health; and the Theory of Nursing Systems that outlines three levels of deliberate nursing actions required to help patients meet self-care needs. The Theory of SelfCare provides an understanding of the concept of self-care in terms of the personal

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care that individuals carry out each day to maintain health and prevent illness. The concepts central to the Theory of Self-Care are self-care demand, self-care ability, and self-care agency. In 1971, Orem outlined the three assumptions fundamental to the theory of selfcare (Orem, 1971). First, human beings continuously and deliberately take action to themselves and to their environments to maintain life and to function in line within their human capabilities. Second, human agency is conceptualized as possessing the ability to act purposively, to identify needs deficits and to effectively respond to them. Third, human agency is put into effect through discovering, developing, and conveying the methods required to identify needs and to take action on behalf of self. The Theory of Self-Care posits that people want to act as agents of their own health care (Orem, 2001). In this regard, individuals put into place actions that enable them to function, develop, maintain health, and achieve a sense of well-being. The ideas central to the Theory of Self-Care include self-care (posits that through the initiation of actions, people maintain life-span health and well-being) and self-care demand (focuses on the totality of self-care actions individuals carry out daily, at intervals or on a continual basis, to meet self-care requisites and self-care agent). Self-care agents involve themselves in a course of action, or have the capability to engage in a course of action to meet self-care needs. Orem (1995) outlined the self-care requisites that people engage in to maintain health and prevent illness. Self-care requisites are classified according to three types: universal (those required by all, regardless of their age), developmental (self-care requisites to be met at a particular stage in a person’s development), and health deviation (self-care requisites that need to be met during ill-health). Self-care requisites focus on the maintenance and intake of food, air, and water at a level commensurate with (a) human functioning, (b) development, and (c) well-being. The latter is defined as the generation and maintenance of living conditions that support life processes, the preservation of structural integrity, and the maintenance and promotion of functional integrity (Orem, 1995, p. 108). Developmental self-care requisites promote processes of life and maturation and focus on preventing conditions that interfere with maturing and development. Health deviation self-care is necessary in situations of illness, injury, and disease. Health deviation requisites are associated with patients’ needs and self-care ability at various junctures along the health–illness continuum (Orem, 1995). The Self-Care Deficit Theory provides guidance on when nursing is required and the type of nursing care that is needed. Nursing care is required when people are limited in their ability to self-care or are incapable of meeting their self-care needs. Orem identified three types of nursing systems—wholly compensatory, partially compensatory, and educative supportive. The goal is to compensate for or overcome a patient’s self-care deficits. In this regard, Orem offers five methods (i.e., helping acting for another, guiding another, supporting another, providing an environment for promoting personal development in relation to meeting future demands, and teaching another). Orem (2001) renamed the three systems of nursing as the practice fields in nursing. The metaparadigm concepts embedded within the Self-Care Deficit Theory are person, health, environment, and nursing. Person is conceptualized as a rational human being who takes self-determined action to reach health-related goals. Health is described in the context of it being more than the absence of disease. Orem does

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Part I  Introduction

not clearly define the environment; however, she does assert that the environment and health are mutually related. The Self-Care Deficit Theory of Nursing has a special contribution to make to nursing and midwifery in terms of delineating its unique function with the multidisciplinary team and its contribution to patient care.

Theory of Human Caring Jean Watson first published the Theory of Human Caring in 1979 (Watson, 1979, 1985). Watson’s theory development was influenced by her experiences of conventional nursing knowledge and the theories of earlier pioneers in nursing such as Florence Nightingale and Virginia Henderson. In addition, Watson acknowledges the influences of nursing theorists such as Madeleine Leininger, Hildegard Peplau, and the philosophical work of Sally Gadow, a nursing philosopher (Watson, 1988a, 1997). Watson’s (1979, 1985) theory arose from her desire to bring renewed meaning and dignity to the domain of nursing and patient care. She believed that nursing at that time had limited scope due to the strong influence of the medical model and traditional biomedical science models of care. In 1988, Watson renamed her work Nursing: Human Science and Human Care: A Theory of Nursing, to further describe the social and ethical responsibilities of nursing, and to delineate the concepts central to human caring (Watson, 1988b). Watson viewed caring to be the essence of nursing and the basis of all nursing actions. Caring, in her view, encompassed both the art and the science of nursing. Watson (1988a, 2007) also discussed caring from a moral perspective and hoped that her theory would assist nurses with including a moral base when caring for patients. In 2002, in an interview with Jacqueline Fawcett, Watson stated that the Theory of Human Caring was “a foundational ethic and a philosophy for health care professionals” (Watson, 2002, p. 215). In addition, Watson (1979, 1985) presented 10 carative factors that provided a framework for the operationalization of caring in practice: formation of a humanistic altruistic system of values; instillation of faith-hope; cultivation of sensitivity to self and others; development of a helping trusting relationship; promotion and acceptance of the expression of positive and negative feelings; systematic use of the scientific problem-solving method for decision making; promotion of interpersonal teaching and learning; provision for supportive, protective, and corrective mental, physical, sociocultural, and spiritual environment; assistance with the gratification of human needs; and allowing for existential phenomenological forces. The metaparadigm concepts discussed within the Theory of Human Caring are person, health, environment, and nursing. According to Watson’s theory, the uniqueness of the individual in the caring relationship is emphasized. This relationship is also based on past experiences of caring. From Watson’s perspective, health is more than the absence of disease and illness. Nursing is associated with a number of human care transactions mediated by professional, personal, scientific, aesthetic, and ethical components.

Science of Unitary Human Beings Martha Rogers described nursing as both science and art, with the emphasis on delineating the scientific focus so as to position nursing with other disciplines. Her writing was based on general systems theory (Von Bertalanffy, 1968) and quantum field theory that had been developed in physics (Itzykson & Zuber, 1980). Rogers

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conceptualized human beings as more than the sum of the parts, and thus rejected the reductionist model of biopsychosocial spiritual cultural persons. This assumes that one can know the whole by summing the parts. She postulated that humans (and the environment) are pan-dimensional energy fields that are characterized by open boundaries, rhythmic pattern, and organization (Rogers, 1970). Homeodynamic principles were embedded in Rogers’s conceptualization. These included resonancy (the ordered arrangement of the rhythms characterizing humans and environment), helicy (the unpredictable but continuous, nonlinear evolution toward increasing complexity and diversity), and integrality (the mutual continuous relationship between human and environmental fields) (Rogers, 1970). Rogers’s grand theory laid the foundation for several other theoretical perspectives developed based on Rogers’s principles. These included the works of Margaret Newman (1986), the Theory of Health as Expanding Consciousness; Rosemarie Parse (1981), the Theory of Man-Living-Health (later named the Theory of Human Becoming (1992); Joyce Fitzpatrick (1983), the Life Perspective Rhythm Model; and Pamela Reed (1991), the Theory of Self-Transcendence. Rogers’s theory also sparked much research from the mid-1970s to the present. Rogers believed that the core concepts of nursing were person and environment, and placed the emphasis on these two concepts when framing the metaparadigm of nursing. For Rogers, the goal of professional nursing practice was the art of nursing. Nurses were expected to apply their scientific knowledge of wholistic humans in the professional practice, thus assisting individuals to move toward health. Rogers’s Science of Unitary Human Beings Theory has been used as a framework to guide nursing education, practice, and research. Klemm and Stashinko (1997) describe a creative way to teach unitary knowing based on Rogers’s Science of Unitary Human Beings. They are of the opinion that Rogers’s theory is complex and that traditional methods of teaching–learning do not work well with it. Their creative strategy provides opportunity for graduate students to analyze Rogers’s theory and reflect on its application in practice and research. Teaching strategies for this new method of teaching the theory include use of posters, storytelling, and quizzes to evaluate whether the students read the preassigned readings. Handouts summarizing the theory in easy-to-understand terms and objectives were provided to students. Group work and discussion follow formal teaching about the theory. This is an interesting teaching approach for Rogers’s theory; however, there is no mention of evaluating the students’ learning in this class compared to the learning in a more traditional learning environment. DeSimone (2006) described the redesign of a curriculum to facilitate critical thinking in accelerated bachelor’s degree nursing students at one school. Rogers’s theory is the theoretical framework guiding the curriculum. Faculty proposed that Rogers’s unitary view of human beings supports critical thinking as a developing process (DeSimone, 2006). Critical thinking was measured at the beginning and at the end of the educational program. Results indicated an increase in critical thinking. Further research is needed with larger samples. Larkin (2007) studied how traditional support groups and hypnosis support groups affect self-defined health-promoting goals and power as knowing participation in change among those with chronic illness. Rogers’s (1970, 1990) Theory of Unitary Human Beings was the framework for this study. Power as knowing participation in change was measured using the Power as Knowing Participation Change Tool (PKPCT), Version II (Barrett, 1998). Self-defined health-promoting goals were measured

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with the Self-Defined Health-Promoting Goals Scale (Matas, 1997). Both groups showed enhanced power and progression toward health goals. Lewandowski (2004) studied the effect of guided imagery on chronic pain and power over a 4-day period. Rogers’s Science of Unitary Human Beings was the framework for this research. Randomly assigned into the control group or the treatment group were 42 patients with chronic pain. The PKPCT (Barrett, 1986) was used to measure power. Results showed that guided imagery was effective and reduced chronic pain in the last 2 days of the study. There was no difference in power between the groups. Further studies are recommended to validate the PKPCT and compare it to other tool instruments measuring power.

MIDDLE RANGE THEORIES Middle range theories are more explicit and less generalizable than grand theories. Middle range theories are used to guide research and offer direction for nursing intervention in practice. The middle range theories presented in the next section developed from a synthesis of the empirical and theoretical literature. According to Smith and Liehr (2014), the theories of uncertainty and unpleasant symptoms are grounded in the social sciences and the Theory of Meaning is based in the human sciences.

Theory of Meaning The Theory of Meaning was introduced by Patricia Starck in 1979 (Starck, 1979). The theory is founded on the theoretical assertions of psychiatrist Viktor Frankl. The initial application of the theory was with persons with psychiatric and psychological conditions. The concepts that evolved from Frankl’s work are central to meaning, and include life purposes, freedom to choose, and human suffering. The hypothesis of life purpose is central to the Theory of Meaning and is related to existence. The search for meaning is in essence a search for life’s purpose (Frankl, 1973) or a “that to which one may feel called to and to which one is dedicated” (Starck, 2014, p. 91). Freedom to choose is defined as “the process of selecting among options over which one has control” (p. 94). The third concept, human suffering, is a subjective experience that can span the range from simple discomfort to the individual experiencing extreme anguish and despair (p. 96). These three concepts are related through the road from meaning to life purpose and experiencing suffering along the way as one chooses options. The theory has been used as a framework for a number of studies focusing on suffering and loss. In a 1992 ethnographic study, Starck (1992) identified the subjective nature of suffering for residents in a nursing home setting. This suffering was most acutely felt by residents who did not have family support. The meaning in suffering test (MIST) was designed to test individuals’ perception of the extent to which they have found meaning in suffering (Starck, 1983). The theory has been applied across a wide selection of clinical situations including studies focusing on the terminally ill and staff working in a nursing home environment. According to Starck (2008, 2014) the Theory of Meaning has the potential to be used in interdisciplinary projects. Nevertheless, many researchers have used the individual concepts of the theory to guide their research, as opposed to Starck’s Theory of Meaning in totality. The

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concept of meaning has been studied in various patient populations such as those with breast cancer (Coward & Kahn, 2005) and myocardial infarction (MI) (Baldacchino, 2010). In Norway, a study has been conducted investigating the relationship between meaning in life and physical, emotional, functional, and social well-being in cognitively intact nursing home residents (Haugan, 2013). Konkolÿ Thege and colleagues (2009) have provided insight into decreased meaning in life and smoking tobacco in ­Hungary. Their results indicated that there were significant differences in meaning of life between nonsmokers and daily smokers. The purpose in life concept has been studied in patient populations such as those with rheumatoid arthritis (RA) (Verduin et al., 2008) and adult cocaine abusers in treatment (Martin, MacKinnon, Johnson, & Rohsenow, 2011). There is a need for future research to focus on Starck’s Theory of Meaning in its totality and particularly in interdisciplinary research.

Theory of Uncertainty in Illness The Theory of Uncertainty in Illness was initially developed by Mishel in 1988 in response to the uncertainty that patients experience during specific illness situations. The theory comprises three key themes: antecedents of uncertainty, appraisal of uncertainty, and coping with uncertainty (Mishel, 2014; Mishel & C ­ layton, 2008). Uncertainty and cognitive schema are the main concepts of the theory. The theory provides a framework for selecting interventions to improve psychological and behavioral outcomes under conditions of uncertainty. According to the theory, uncertainty is generated when components of illness, treatment-related stimuli, and illness-related events have the characteristics of complexity, inconsistency, randomness, unpredictability, and a lack of information in situations that are important to the person (Mishel, 1981, 1988). The theory has been used as a design for a number of studies. It has also been applied across a wide selection of clinical situations. For example, Lin, Yeh, and Mishel (2010), in a cross-sectional study, developed a conceptual model that captured coping and growth in Taiwanese parents living with the ongoing uncertainty around their children’s health. The theory of uncertainty guided the development of the conceptual model for the study. The theory also provided a framework for an intervention focusing on specific cognitive and behavioral strategies to control uncertainty in women who survived cancer (Germino et al., 2013). Researchers conducting qualitative and quantitative studies with cancer populations have used the Theory of Uncertainty in Illness as the conceptual framework. Bailey, ­Wallace, and Mishel (2007) conducted a qualitative study exploring the problems and uncertainties of 10 older men with prostate cancer and the strategies they used to manage these problems and uncertainties after undergoing watchful waiting. The three key themes of the theory were used to organize the interview data. The experiences and concerns of the participants supported the theory of uncertainty. ­Clayton, Mishel, and Belyea (2006) used the theory of uncertainty along with evidence from the literature on breast cancer survivors to provide a framework for identifying variables thought to influence psychological and behavioral outcomes when there is uncertainty. Detprapon, Sirapo-ngam, Sitthimongkol, and Vorapongsathorn (2009) tested the uncertainty in illness theory to determine factors influencing quality of life among 240 head and neck cancer patients who were recruited from five hospitals in Bangkok. The Theory of Uncertainty in Illness has been employed by researchers when investigating cardiac patients with an implantable cardioverter defibrillator (ICD).

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Flemme and colleagues (2005) used the theory of uncertainty to guide their study with a sample of patients who have an ICD. The purpose of this study was to describe uncertainty and quality of life in this patient group. Uncertainty was measured using the Mishel Uncertainty in Illness Scale-Community Form (MUIS-C). Carroll and Arthur (2010) compared patients’ uncertainty, optimism, and anxiety in a population receiving their first ICD for either primary or secondary prevention of sudden cardiac death (SCD), and to examine whether the two groups differed in uncertainty at diverse time points. Results indicated a downward trend in uncertainty scores as measured using MUIS-C over time.

The Theory of Unpleasant Symptoms The Theory of Unpleasant Symptoms (TOUS) is a middle range theory developed by nurse colleagues who wanted to understand patients’ experiences of multiple symptoms and the interactive nature of symptoms (Lenz & Pugh, 2014; Lenz, Pugh, Milligan, Gift, & Suppe, 1997). The TOUS includes the following three interrelated concepts: the symptoms, influencing factors and performance outcomes that influence the tendency to develop the symptom(s), and the manifestations of the symptom experience. The symptom experience has a direct impact on cognitive, physical, and social functioning. In accordance with this theory, a symptom can occur in isolation or in conjunction with another symptom. The importance of assessing the occurrence of multiple symptoms simultaneously is highlighted, since the pattern of multiple symptom concurrence can be seen across clinical populations. A number of studies have recently reaffirmed the synchronic nature and multifaceted nature of symptoms in people with different clinical conditions. For example, Hutchinson and Wilson’s (1998) findings emphasize the multifaceted nature of symptoms in people with Alzheimer’s disease including the factors influencing symptoms’ occurrence as well as outcomes. McCann and Boore (2000) adopted the Theory of Unpleasant Symptoms to underpin a study investigating fatigue in patients with renal failure who required maintenance hemodialysis. This study highlighted the multifaceted relationship between psychological, physiological, and situational factors influencing fatigue and end-stage renal disease (ESRD).

Theory of Comfort The Theory of Comfort was developed by Kolcaba in the 1990s, who continues to refine it. Initially she performed a concept analysis of comfort using literature from different disciplines (Kolcaba & Kolcaba, 1991). In her theory, she has defined three types of comfort—relief, ease, and transcendence (Kolcaba, 1994, 2001, 2003). Relief is defined as having a discomfort alleviated or eliminated (Kolcaba, 2001, 2003). Kolkaba defined ease as the absence of discomforts; in other words, received ease from pain discomfort (Kolcaba, 2001, 2003). Transcendence is defined as the ability to “rise above” or transcend the discomforts when they cannot be eliminated (Kolcaba, 2001, 2003). In the comfort theory, the comfort concept occurs within four contexts of experience: physical, psychospiritual, sociocultural, and environmental (Kolcaba, 2001, 2003). Kolcaba has defined comfort as “the immediate state of being strengthened through having the human needs for relief, ease, and transcendence addressed in four contexts of experience (physical, psychospiritual, sociocultural, and environmental)” (2003, p. 251). In her Theory of Comfort, Kolcaba has developed a taxonomic structure of

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comfort by using the three types of comfort crossed by the four contexts of experience creating a 12-cell table (Kolcaba, 1991, 2003). All comfort needs can be placed on this grid and it can be used in any situation where comfort is the concept of interest. Other concepts in the comfort theory are health care needs of the patient, intervening variables, health-seeking behavior and institutional integrity, best policies, and best practices. The Theory of Comfort has been used to guide research studies with a wide range of patient populations. Apostolo and Kolcaba (2009) used the Theory of C ­ omfort to guide their intervention study investigating the comfort effect of guided imagery on hospitalized patients with mood disorders. A guided imagery CD was provided to the 30 patients in the experimental group, who were instructed to listen to it every day for 10 days. The results indicated an increase in comfort level along with decreases in depression, anxiety, and stress. Dowd, Kolcaba and Steiner (2000) developed and tested an intervention with cognitive strategies to improve bladder function and increase comfort in 40 patients with reduced bladder function. The Theory of Comfort was the guiding framework for the study. The researchers believed that enhancing comfort could help with health-seeking behaviors. In 2003, this group of researchers, Dowd, Kolcaba, and Steiner, added coaching to the original intervention and tested it in a sample of patients with compromised urinary bladder syndrome (CUBS). Again, the Theory of Comfort guided development of the intervention and the comfort measures. The Theory of Comfort has been used as the conceptual configuration in studies related to instrument development. Dowd, Kolcaba, and Steiner (2006) established the reliability of the Healing Touch Comfort Questionnaire (HTCQ) in a study with 56 participants familiar with healing touch (HT). The HTCQ was developed to measure the effects of HT and demonstrate the efficacy of this therapy. Researchers have conducted a number of studies guided by Kolcaba’s Theory of Comfort where comfort measures are the focus. Kolcaba, Dowd, Steiner, and Mitzel (2004) investigated the efficacy of hand massage, a noninvasive holistic intervention, as a means of increasing comfort of hospice patients. Comfort increased only slightly for patients who received the hand massage for the 3-week period, and it was higher than in the comparison group. In 2006, Kolcaba, Schirm, and Steiner looked at the effects of hand massage in nursing home residents at two facilities. There was difficulty with training the staff to perform the hand massage, so nursing students were trained to provide the intervention. Results indicated high comfort levels in both the intervention and control groups at the end of the study. The comforting presence of the nursing students was given as a possible reason for the increased comfort in both groups. The Theory of Comfort has been used in practice environments as a framework for care. Kolcaba, Tilton, and Drouin (2006) describe the use of the comfort theory in a New England hospital. The comfort theory was chosen because it reflected the organization’s philosophy. Education and training on the comfort theory were provided for staff and many new initiatives such as comfort rounds were introduced. The Theory of Comfort has education applications also. Goodwin, Sener, and Steiner (2007) described the selection of the Theory of Comfort to guide the curriculum in a fast-track nursing program. They reported the development of several learning objectives embracing the Theory of Comfort. Learning outcomes were measured in a number of ways ranging from classroom assessments to reflective journals. ­Further research is needed with regard to the use of the Theory of Comfort as a ­curriculum guide.

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The Theory of Self-Efficacy The Theory of Self-Efficacy was developed by Barbara Resnick and is based on social cognitive theory. Self-efficacy is defined as “an individual’s judgment of his or her capabilities to organize and execute courses of action” (Resnick, 2014). Major concepts in the theory are self-efficacy expectations and outcome expectations. Self-efficacy expectations are defined as judgments about one’s own ability to accomplish a particular task. Outcome expectations are beliefs that certain behaviors result in certain outcomes; however, individuals do not necessarily believe that they are capable of executing the task at hand. Resnick (2014) has identified four information sources that influence judgment about one’s own self-efficacy: (a) enactive attainment (actual performance of the behavior); (b) vicarious experience (watching others like themselves perform the behavior); (c) verbal persuasion (encouragement by others); and (d) physiological feedback (bodily experience while performing the task) (Resnick, 2014). These four sources of information can influence self-efficacy and the outcome expectations. They also interact with the environment and an individual’s characteristics. Resnick and her colleagues have a vast program of research related to self-­efficacy and physical exercise among different populations. Shaughnessy and R ­ esnick (2009) used the Theory of Self-Efficacy structure to develop an exercise intervention for subacute stroke survivors. This framework was used to gather information from participants, and then utilize that data to customize a program designed to optimize their self-efficacy and increase exercise behavior. Galik et al. (2008) tested the feasibility and impact of a two-tiered motivational intervention, the Restorative Care Intervention for the Cognitively Impaired. Their sample was nursing home residents with moderate to severe cognitive impairment. The Theory of Self-Efficacy was the guiding framework for this study (Bandura, 1997). Resnick and D’Adamo (2011) tested a model of the factors that influence exercise activities. This model of exercise behavior embraces the Theory of Self-Efficacy (Bandura, 1997). Results indicated that only a small percentage of the variance in exercise behavior was explained. Further research is needed to identify additional variables. Nahm et al. (2010) developed and evaluated a structured hip fracture prevention website for older adults using a Social Cognitive Theory (SCT) framework. Evaluation testing revealed that the use of a theory-based, structured hip fracture prevention website had potential as a sustainable web structure for online health behavior change interventions. Physical exercise and self-efficacy have been the focus of study for other researchers also. Hays, Pressler, Damush, Rawl, and Clark (2010) were interested in whether exercise adoption could be predicted from self-efficacy, outcome expectations, and exercise self-definition. The guiding model for their study was an expanded model SCT (Bandura, 1997). Self-efficacy was measured using three items related to confidence in exercise performance. Millen and Bray (2009) studied the effects of an intervention targeting self-efficacy, outcome expectations, and adherence to upperbody resistance exercise after cardiac rehabilitation. Bandura’s (1997) sources of self-­ efficacy—mastery experience, vicarious experience, verbal persuasion, and physiological and affective states—were employed as ways to measure self-efficacy. There are a number of studies where the concept of self-efficacy is included but the Resnick theory is not identified as the guiding theoretical framework. Many of these studies were related to physical exercise. Duncan, Pozehl, Norman, and Hertzog (2011) measured the effectiveness of the Exercise Adherence Management Program (EAMP) in improving patients’ exercise self-efficacy and adherence.

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Self-efficacy provides a conceptual framework for this study. The researchers used randomized controlled trial (RCT) design with 20 patients with heart failure (HF) who participated in a resistance and aerobic exercise training program during two phases. Results indicated an improvement in exercise self-efficacy during the study period. However, the exercise adherence declined during the unsupervised phase (Duncan et al., 2011). The aim of a study in the Netherlands was to examine the effect of a 12-week pedometer-based exercise counseling strategy on enhancing daily physical activity for chronic obstructive pulmonary disease (COPD) patients (Hospes, Bossenbroek, Ten Hacken, van Hengel, & de Greef, 2009). Self-efficacy was measured by using a physical self-efficacy scale (Ryckman, Robbins, Thornton, & Contrell, 1982). There was no significant difference for self-efficacy between the groups (Hospes et al., 2009). Irvine et al. (2011) examined the effect of a workplace physical activity (PA) website on improving PA of sedentary workers. The study used RCT design. SCT and the theory of reasoned action guided the study framework. Self-efficacy was measured with four questions related to perceived confidence with participating in exercise. The results of the study indicated a medium impact on self-­efficacy (Irvine et al., 2011). Gau, Chang, Tian, and Lin (2011) measured the effectiveness of a “birth ball” exercise program on childbirth self-efficacy and childbirth pain. A birth ball is a standard physiotherapy ball approximately 55 to 75 cm in diameter. In addition, the researchers tested the mediation effect of childbirth self-efficacy between a birth ball exercise program and childbirth pain. The researchers used randomized control design (RCD) with a sample composed of 48 intervention group and 39 control group women from China. The Childbirth Self-Efficacy Inventory (CBSEI) measured maternal confidence for labor and birth (Lowe, 1993). The results of the study revealed, statistically, that birth ball exercise significantly improved childbirth self-efficacy and childbirth pain (Gau et al., 2011). Grim, Hortz, and Petosa (2011) examined the impact of 10-week web-based PA intervention among 233 college students divided into three groups: web-based, PA, and general health. The intervention included SCT behavioral skill-building intervention and exercise. Self-efficacy for physical activity was measured using a 14-item scale developed by Garcia and King (1991). The researchers found statistically significant improvement in vigorous PA, self-regulation, and outcome expectancy values for web-based and PA course groups (Grim et al., 2011).

The Theory of Nursing Intellectual Capital Covell (2008) developed the Theory of Nursing Intellectual Capital in response to her perceived need for a better understanding of the influence of nurses’ knowledge, skills, and experience on patient and organizational outcomes (Covell, 2008). The theory was developed by using the Walker and Avant (2005) strategies of concept and theory derivation. It was derived from intellectual capital theory and conceptualizes the human capital of nurses providing direct care to hospitalized patients. Seven concepts and their relationships were identified. Future research could include testing the theory with nurses in different roles, nonnurses, nurse educators, and administrators. However, in each of these situations examination of the concepts would be necessary prior to use of the theory because the factors and outcomes influencing nursing capital in specific situations may vary (Covell, 2008). In 2008, Covell and Sidani (2013) conducted a study in six Canadian

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acute care hospitals to test selected propositions in the Theory of Nursing Intellectual Capital. The propositions associated with the nursing human capital concept were supported, whereas the propositions associated with the employer support concept were not. Covell and Sidani (2013) recommend further clarity and refinement with regard to the measurement of some of the theory’s concepts. Research studies testing this theory are needed.

Theory of Peaceful End of Life Ruland and Moore (1998) developed the Theory of Peaceful End of Life from their understanding and interpretation of the standards of the peaceful end of life for terminally ill patients. The standards were developed by expert clinical nurses in Norway working with terminally ill patients. The final standard had 16 outcome criteria (Ruland & Moore, 1998). Examples of these patient outcomes included not experiencing nausea, thirst, or pain, as well as not having to die alone. For development of the theory, these outcome criteria were examined for common themes, and the original 16 standard outcomes were reduced to 5 outcome indicators (concepts): not experiencing pain; experiencing comfort; dignity and respect; being at peace; and being close to others (Ruland & Moore, 1998). Six relational statements were developed using these five concepts. These relational statements linked nursing interventions to the concepts. Each concept had at least two relational statements, whereas the concept of being at peace had as many as six relational statements (Ruland & Moore, 1998). This Theory of Peaceful End of Life reflects the complexity of nursing terminally ill patients at the end of life. This is a significant middle range theory because it can guide nursing practice at the end of life. The Theory of Peaceful End of Life could be used to guide nursing education programs in end-of-life care so that student nurses and registered nurses have a thorough understanding of the complexity involved in providing nursing care to terminally ill patients. However, future research is needed to test this theory and to validate its usefulness in research, practice, and education.

SUMMARY This chapter includes an overview of selected grand theories in nursing; that is, the Adaptation Model (Callista Roy), the Self-Care Deficit Theory of Nursing (Dorothea Orem), the Theory of Human Caring (Jean Watson), and the Science of Unitary Human Beings (Martha Rogers). Seven middle range theories are also described: the Theory of Meaning (Starck), the Theory of Uncertainty in Illness (Mishel and Clayton), the Theory of Unpleasant Symptoms (Lenz, Pugh, Milligan, Gift, and Suppe), the Theory of Comfort (Kolcaba), the Theory of Self-Efficacy (Resnick), the Theory of Nursing Intellectual Capital (Covell), and the Theory of Peaceful End of Life (Ruland and Moore). The grand theories are described as related to the broad theoretical boundaries inherent in nursing metaparadigm concepts. Research, education, and professional practice examples are provided for the middle range theories as a beginning assessment of the external validity, pragmatic adequacy, and usefulness of these theories. The review of the theories in this chapter demonstrated that grand theories are broad in nature and application. Conversely, middle range theories are more easily applied to nursing research. The remainder of this book focuses on the application of specific middle range theories to nursing research in an Irish context.

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Part I  Introduction Flemme, I., Edvardsson, N., Hinic, H., Jinhage, B. M., Dalman, M., & Fridlund, B. (2005). Longterm quality of life and uncertainty in patients living with an implantable cardioverter defibrillator. Heart and Lung, 34(6), 386–392. Frankl, V. (1973). The doctor and the soul. New York, NY: Vintage. Galik, E., Resnick, B., Gruber-Baldini, A., Nahm, E., Pearson, K., & Pretzer-Aboff, I. (2008). Pilot testing of the restorative care intervention for the cognitively impaired. Journal of the American Medical Directors Association, 9(7), 516–522. Garcia, A., & King, A. (1991). Predicting long-term adherence to aerobic exercise: A comparison of two models. Journal of Sport Exercise Psychology, 13, 394–410. Gau, M., Chang, C. Y., Tian, S. H., & Lin, K. C. (2011). Effects of birth ball exercise on pain and self-efficacy during childbirth: A randomised controlled trial in Taiwan. Midwifery, 27(6), e293–e300. Germino, B. B., Mishel, M. H., Crandell, J., Porter, L., Blyer, D., Jenerette, C., & Gil, K. (2013). Outcomes of an uncertainty management intervention in younger African American and Caucasian breast cancer survivors. Oncology Nursing Forum, 401, 82–92. Goodwin, M., Sener, I., & Steiner, S. (2007). A novel theory for nursing education: Holistic comfort. Journal of Holistic Nursing, 25(4), 278–285. Grim, M., Hortz, B., & Petosa, R. (2011). Impact evaluation of a pilot web-based intervention to increase physical activity. American Journal of Health Promotion, 25(4), 227–230. Haugan, G. (2013). Meaning-in-life in nursing-home patients: A valuable approach for enhancing psychological and physical well-being? Journal of Clinical Nursing. Advance online publication. doi:10.1111/jocn.12402 Hays, L., Pressler, S., Damush, T., Rawl, S., & Clark, D. (2010). Exercise adoption among older, low-income women at risk for cardiovascular disease. Public Health Nurse, 27(1), 79–88. Helson, H. (1964). The adaptation level theory. New York, NY: Harper & Row. Hospes, G., Bossenbroek, L., Ten Hacken, N. H., van Hengel, P., & de Greef, M. H. (2009). Enhancement of daily physical activity increases physical fitness of outclinic COPD patients: Results of an exercise counseling program. Patient Education & Counseling, 75(2), 274–278. Hutchinson, S. A., & Wilson, H. S. (1998). The Theory of Unpleasant Symptoms and Alzheimer’s disease. Scholarly Inquiry for Nursing Practice, 12(2), 143. Irvine, A., Philips, L., Seeley, J., Wyant, S., Duncan, S., & Moore, R. W. (2011). Get moving: A web site that increases physical activity of sedentary employees [Includes abstract]. American Journal of Health Promotion, 25(3), 199–206. Itzykson, C., & Zuber, J. B. (1980). Quantum field theory. New York, NY: McGraw-Hill. Johnson, D. E. (1980). The behavioral system model for nursing. In J. P. Riehl & C. Roy (Eds.), Conceptual models for nursing practice (2nd ed., pp. 205–216). New York, NY: Appleton-Century-Crofts. Klemm, P., & Stashinko, E. (1997). Martha Rogers’ Science of Unitary Human Beings: A participative teaching-learning approach. Journal of Nursing Education, 36(7), 341–343. Kolcaba, K. (1994). A Theory of Comfort for nursing. Journal of Advanced Nursing, 19, 1178–1184. Kolcaba, K. (2001). Evolution of the mid-range Theory of Comfort for outcomes research. Nursing Outlook, 49(2), 86–92. Kolcaba, K. (2003). Comfort theory and practice. New York, NY: Springer Publishing Company. Kolcaba, K., Dowd, T., Steiner, R., & Mitzel, A. (2004). Efficacy of hand massage for enhancing the comfort of hospice patients. Journal of Hospice and Palliative Nursing, 6(2), 91–102. Kolcaba, K., Schirm, V., & Steiner, V. (2006). Effects of hand massage on comfort of nursing home residents. Geriatric Nursing, 27(2), 85–91.

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Kolcaba, K., Tilton, C., & Drouin, C. (2006). Use of comfort theory to enhance the practice environment. The Journal of Nursing Administration, 36(11), 538–544. Kolcaba, K. Y. (1991). A taxonomic structure for the concept comfort. Image: Journal of Nursing Scholarship, 23(4), 237–240. Kolcaba, K. Y., & Kolcaba, R. J. (1991). An analysis of the concept of comfort. Journal of Advanced Nursing, 16(11), 1301–1310. Konkolÿ Thege, B., Bachner, Y. G., Martos, T., & Kushnir, T. (2009). Meaning in life: Does it play a role in smoking? Substance Use & Misuse, 44(11), 1566–1577. Larkin, D. (2007). Ericksonian hypnosis in chronic care support groups: A Rogerian exploration of power and self-defined health-promoting goals. Nursing Science Quarterly, 20(4), 357–369. doi:10.1177/0894318407306539 Lenz, E. R., & Pugh, L. C. (2014). The Theory of Unpleasant Symptoms. In M. J. Smith & P. Liehr (Eds.), Middle range theory for nursing (3rd ed., pp. 165–196). New York, NY: Springer Publishing Company. Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. (1997). The middle-range Theory of Unpleasant Symptoms: An update. Advances in Nursing Science, 19(3), 14–27. Lewandowski, W. (2004). Patterning of pain and power with guided imagery. Nursing Science Quarterly, 17(3), 233–241. doi:10.1177/0894318404266322 Lin, L., Yeh, C., & Mishel, M. H. (2010). Evaluation of a conceptual model based on Mishel’s theories of uncertainty in illness in a sample of Taiwanese parents of children with cancer: A cross-sectional questionnaire survey. International Journal of Nursing Studies, 47(12), 1510–1524. Lowe, N. K. (1993). Maternal confidence for labor: Development of the childbirth self-efficacy inventory. Research in Nursing and Health, 16, 141–149. Martin, R. A., MacKinnon, S., Johnson, J., & Rohsenow, D. J. (2011). Purpose in life predicts treatment outcome among adult cocaine abusers in treatment. Journal of Substance Abuse Treatment, 40, 183–188. Matas, K. (1997). Therapeutic touch: A model for community-based health promotion. In M. Madrid (Ed.), Patterns of Rogerian knowing (pp. 218–229). New York, NY: National League for Nursing Press. McCann, K., & Boore, J. R. (2000). Fatigue in persons with renal failure who require maintenance haemodialysis. Journal of Advanced Nursing, 32(5), 1132–1142. Millen, J., & Bray, S. R. (2009). Promoting self-efficacy and outcome expectations to enable adherence to resistance training after cardiac rehabilitation. Journal of Cardiovascular Nursing, 24(4), 316–327. Mishel, M. H. (1981). The measurement of uncertainty in illness. Nursing Research, 3, 258–263 Mishel, M. H. (1988). Uncertainty in illness. Journal of Nursing Scholarship, 20(4), 225–232. Mishel, M. H. (2014). Theories of Uncertainty in Illness. In M. J. Smith & P. Liehr (Eds.), Middle range theory for nursing (3rd ed., pp. 53–86). New York, NY: Springer Publishing Company. Mishel, M. H., & Clayton, M. F. (2008). Uncertainty in illness theories. In M. J. Smith & P. Liehr (Eds.), Middle range theory for nursing (2nd ed., pp. 55–84). New York, NY: Springer Publishing Company. Nahm, E., Barker, B., Resnick, B., Covington, B., Magaziner, J., & Brennan, P. (2010). Effects of a social cognitive theory-based hip fracture prevention web site for older adults. Computers, Informatics, Nursing, 28(6), 371–377. Newman, M. A. (1986). Health as expanding consciousness. Burlington, MA: Jones & Bartlett. Orem, D. E. (1971). Nursing: Concepts of practice. New York, NY: McGraw-Hill. Orem, D. E. (1995). Nursing: Concepts of practice (5th ed.). St. Louis, MO: C. V. Mosby.

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Part I  Introduction Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.). New York, NY: McGraw-Hill. Parse, R. R. (1981). Man-Living-Health: Theory of nursing. New York, NY: Wiley. Parse, R. R. (1992). Illuminations: The human becoming theory in practice and research. New York, NY: National League for Nursing Press. Reed, P. G. (1991). Toward a nursing theory of self-transcendence: Deductive reformulation using developmental theories. Advances in Nursing Science, 13(4), 64–77. Resnick, B. (2014). The Theory of Self-Efficacy. In M. J. Smith & P. Liehr (Eds.), Middle range theory for nursing (3rd ed., pp. 87–108). New York, NY: Springer Publishing Company. Resnick, B., & D’Adamo, C. (2011). Wellness center use and factors associated with physical activity among older adults in a retirement community. Rehabilitation Nursing, 36(2), 47–53. Rogers, M. E. (1970). An introduction to the theoretical basis of nursing. Philadelphia, PA: F. A. Davis. Rogers, M. E. (1990). Nursing: Science of unitary, irreducible, human beings: Update 1990. In E. A. M. Barrett (Ed.), Visions of Rogers’ science-based nursing (pp. 5–12). New York, NY: National League for Nursing Press. Roy, C. (1970). Adaptation: A conceptual framework for nursing. Nursing Outlook, 18(3), 42–45. Roy, C. (1980). The Roy Adaptation Model. In J. P. Riehl & C. Roy (Eds.), Conceptual models for nursing practice (2nd ed., pp. 179–188). Norwalk, CT: Appleton-Century-Crofts. Roy, C. (1984). Introduction to nursing: An Adaptation Model (2nd ed.). Englewood Cliffs, NJ: Prentice Hall. Roy, C., & Roberts, S. (1981). Theory construction in nursing: An Adaptation Model. Englewood Cliffs, NJ: Prentice Hall. Ruland, C. M., & Moore, S. M. (1998). Theory construction based on standards of care: A proposed Theory of the Peaceful End of Life. Nursing Outlook, 46(4), 169–175. Ryckman, R. M., Robbins, M. A., Thornton, B., & Contrell, P. (1982). Development and validation of a physical self-efficacy scale. Journal of Personality and Social Psychology, 42, 891–900. Shaughnessy, M., & Resnick, B. (2009). Using theory to develop an exercise intervention for patients post stroke. Topics in Stroke Rehabilitation, 16(2), 140–146. Smith, M. J., & Liehr, P. R. (Eds.). (2014). Middle range theory for nursing (3rd ed.). New York, NY: Springer Publishing Company. Starck, P. L. (1979). Spinal cord injured clients’ perception of meaning and purpose in life, measurement before and after nursing intervention. Dissertation Abstracts International, 40(10), 4741. (UMI No. 8007891) Starck, P. L. (1983). Patients’ perceptions of the meaning of suffering. The International Forum for Logotherapy, 6, 110–116. Starck, P. L. (1992). Suffering in a nursing home: Losses of the human spirit. The International Forum for Logotherapy: Journal of Search for Meaning, 15(2), 76–79. Starck, P. L. (2008). The Theory of Meaning. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing (2nd ed., pp. 125–144). New York, NY: Springer Publishing Company. Starck, P. L. (2014). The Theory of Meaning. In M. J. Smith & P. Liehr (Eds.), Middle range theory for nursing (3rd ed., pp. 87–108). New York, NY: Springer Publishing Company. Verduin, P. J., de Bock, G. H., Vlieland, T. P. V., Peeters, A. J., Verhoef, J., & Otten, W. (2008). Purpose in life in patients with rheumatoid arthritis. Clinical Rheumatology, 27, 899–908. doi:10.1007/s10067-007-0822-8 Von Bertalanffy, L. (1968). General system theory: Foundations, development, applications. New York, NY: George Braziller.

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Walker, L. O., & Avant, K. C. (2005). Strategies for theory construction in nursing (4th ed.). Upper Saddle River, NJ: Prentice Hall. Watson, J. (1979). Nursing: The philosophy and science of caring. Boston, MA: Little, Brown. Watson, J. (1985). Nursing: The philosophy and science of caring (2nd ed.). Boulder: Colorado Associated University Press. Watson, J. (1988a). Nursing: Human science and human care: A theory of nursing. Norwalk, CT: Appleton-Century-Crofts. Watson, J. (1988b). Watson’s philosophy and theory of caring in nursing. In J. P. Riehl-Sisca (Ed.), Conceptual models for nursing practice (4th ed., pp. 219–236). Norwalk, CT: Appleton & Lange. Watson, J. (1988/2007). Nursing: Human science and human care: A theory of nursing. Norwalk, CT: Appleton-Century-Crofts. (Reprinting 2007. New York, NY: NLN [Jones and Bartlett]). Watson, J. (1997). The Theory of Human Caring: Retrospective and prospective. Nursing Science Quarterly, 10(1), 49–52. doi:10.1177/089431849701000114 Watson, J. (2002). The nurse theorists: 21st-century updates—Jean Watson. Interview by ­Jacqueline Fawcett. Nursing Science Quarterly, 15(3), 214–219.

part ii

Theories Applied to Research

chapter 3

Symptom Management Theory Margaret G. Landers

The Symptom Management Theory was first published in 1994 as a conceptual model of nursing for symptom management, with a revised edition issued in 2001. More recently, it has been recategorized as a middle range theory of nursing designed to guide symptom assessment and treatment in nursing, as well as questions and hypotheses for nursing research. The purpose of this chapter is to present an analysis of the Symptom Management Theory, which is based on publications regarding the development of the theory: “A Model of Symptom Management” (Larson et al., 1994), “Advancing the Science of Symptom Management” (Dodd et al., 2001), and “The Middle Range Theory of Symptom Management” (Humphreys et al., 2008). The analysis is supported by an adaptation of the frameworks proposed by Fawcett (2005) for the analysis and evaluation of theories of nursing. To begin, an analysis of the scope and context of the Symptom Management Theory is provided, including its core concepts and the relationship among concepts. The following evaluative criteria are then applied: significance, internal consistency, parsimony testability, and empirical adequacy. Finally, an analysis is presented of the use of the Symptom Management Theory to guide a study on patients’ experiences of bowel symptom and self-care strategies following sphincter-saving surgery for rectal cancer. The criteria identified by Fawcett (1999, Appendix 1) for choosing a theory to guide a research study are applied.

BASIC DESCRIPTION OF THE THEORY Initially, the Symptom Management Theory was developed as a conceptual model by faculty at the University of California–San Francisco (UCSF) School of Nursing in 1994. Early conceptualizations were presented to provide a framework that would allow for a more structured and organized approach to the study of symptom experience, management strategies, and outcomes of symptom management (Larson et al., 1994). Following their review of earlier models such as Orem’s Self-Care Deficit Theory of Nursing, Larson et al. (1994) concluded that these models focused primarily on either curing the symptom or on the outcomes of symptom management, yet did not adequately address the patient’s role in self-care.

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According to Larson and colleagues, the central thesis of the Conceptual Model of Symptom Management was that in order to be effective in symptom management, nurses should not focus just on the outcomes of symptom management but also seek to understand the total symptom experience from the patient’s perspective (Larson et al., 1994). The strength of the Symptom Management Theory lies in its attempt to understand symptom experiences and symptom management strategies from the patient’s perspective, as well as its comprehensive consideration of the fact that there is an interdependent relationship between the processes of symptom experience and symptom management strategies. The proposed testable relationships among the three concepts of the Symptom Management Theory— symptom experience, symptom management strategies, and symptom outcome— provide a structure for understanding the empirical connections among these concepts, as well as a framework for considering interventions and outcomes for practice. It is therefore appropriately categorized as a middle range explanatory theory.

CORE CONCEPTS The Symptom Management Theory was first introduced as the Symptom Management Conceptual Model (Figure 3.1) by Larson et al. (1994). As initially conceptualized by Larson et al. (1994), symptom management is comprised of three core concepts: symptom experience, symptom management strategies, and symptom outcomes. Symptom experience includes three dimensions: (a) perception of symptoms, (b) the evaluation of the symptoms, and (c) patients’ responses to symptoms. Symptom perception is associated with whether or not people notice a change in their behavior or in the way they are feeling. Evaluation of a symptom refers to the judgment a person makes regarding the symptom in terms of its severity, cause, treatability, and effects (Larson et al., 1994). Thus, evaluation also takes account of the threat created by the symptom such as its risks or disabling consequences. The response to a symptom includes three components: physiological, psychological, and behavioral responses. Physiological responses are the physical manifestations of symptoms. Psychological responses are revealed in cognitive or affective changes (e.g., mood swings, reduced capacity to concentrate, or altered self-esteem). Behavioral changes are conceptualized as the objective manifestations of a symptom such as changes in verbal or social communication, or changes in personal functioning (e.g., social withdrawal). Larson et al. (1994) asserted that one or more of these responses may be evident with any one symptom. A key assumption of the model is that all troublesome symptoms require a response, and that management strategies should not only focus on controlling the outcome of symptom management but on managing the total symptom experience. Following implementation of the intervention, an evaluation of the strategies and outcomes of symptom management is conducted. Symptom status outcomes are clear and measurable outcomes to assess following the implementation of a strategy. Outcomes include the obvious change in symptom status, whereby the symptom is less frequent, less intense, or less distressing (Larson et al., 1994). The Conceptual Symptom Management Model was revised in 2001 (Dodd et al., 2001). Studies were used to provide an evidence-based foundation and to elucidate further the dimensions underpinning perception (e.g., awareness), evaluation



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Figure 3.1  Conceptual Model of Symptom Management. Symptom Experience

Perception of Symptoms

Symptom Management Strategies Patient

Evaluation of Symptoms Family

Response to Symptoms

Health Care System

Health Care Provider

Emotional Status

Symptom Status Outcomes Functional Status

Health Service Utilization

Symptom Status

Mortality Morbidity & Comorbidity

Self-Care Ability Financial Status

Quality of Life

Reprinted with permission from Larson et al. (1994).

(e.g., severity), and responses (e.g., psychological). Relating to symptom experience, Dodd et al. (2001) delineated the specific questions that needed to be asked in relation to the decisions to be made when implementing symptom management strategies. These include: (a) What is the strategy? (b) When is the strategy used? (c) Where is the strategy used? (d) Why is the strategy used? (e) How much of the intervention is used? (f) To whom is the strategy delivered? and (g) How is the strategy delivered? Thus, Dodd et al. (2001) provided a framework for considering symptom management techniques in the context of the self-care strategies implemented by health care professionals, as well as the self-care methods patients adopt at home on a continual basis to manage their symptoms. Dodd et al. (2001) also proposed that symptom management was conceptualized as a dynamic process often dictating changes in strategies over time. In addition, intervention strategies can focus on one or more of the elements of the individuals’ symptoms in order to achieve one or more of the outcomes set. These authors also contended that patients’ nonadherence or nonacceptance of the strategies developed might result in the need for strategies to be changed or modified to ensure optimum outcomes. Relating to symptom experience, Dodd et al. (2001) asserted that symptoms change over time, making symptom identification and evaluation more complex. They also argued that the perception of a symptom can be confusing when symptoms that are closely linked—but fundamentally different from each other, such as pain and anxiety—are present. As well as physiological, psychological, and

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behavioral responses to symptoms, Dodd et al. (2001) also included a sociocultural subcomponent in the revised model. Additionally, they highlighted that “physiological responses to the symptom may in turn activate other negative physiological responses” (Dodd et al., 2001, p. 672). The symptom management process recognizes that a lack of knowledge regarding what response to take and a lack of ability for performing the actions may elicit assistance from others, such as family members, in managing symptoms. In the revised model, the outcome component incorporated eight dimensions; a new dimension, cost, which takes account of financial status health service utilization and receipt of compensation for employees, was added. However, the arrows—representing directions between dimensions and symptoms status (included in the 1994 version of the model, Figure 3.1, Larson et al., 1994)— have been removed. The framework was proposed as a middle range theory in 2008 and renamed the Symptom Management Theory. The theory has been used as the theoretical basis for a number of research studies across a wide range of clinical specialties and populations. Selected published research studies (discussed later) were used in the 2008 publication (Humphreys et al., 2008) to elucidate how one or more of the concepts can be used as a theoretical basis in nursing research. The Symptom Management Theory focuses on the bidirectional conceptual relationships among symptom experience, symptom management strategies, and symptom outcomes (Figures 3.1 and  3.2). These relationships were revised based on research and experiential findings, as well as further conceptualizations by the faculty and graduate students of the UCSF Symptom Management Center. Studies adopting the Symptom Management Theory highlighted the bidirectional nature of the components of symptom experience. In this regard, Facione and Dodd’s (1995) study demonstrated that women’s evaluation and response to a breast symptom can heighten or lessen their perception of that symptom.

RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS According to Dodd et al. (2001), the three domains of nursing science (person, health/ illness, and environment) influence all three concepts of the model: symptom experience, symptom management strategies, and symptom outcomes. The person is understood in the context of demographic, psychological, sociological, and physiological variables. According to Dodd et al. (2001), these variables are viewed as intrinsic to the way a person views and responds to the symptom experience. Gender and developmental variables are also considered, and the latter include the level of development or maturation of an individual. The domain of health and illness is comprised of variables unique to the individual’s health or illness state and includes risk factors, injuries, or disabilities. In addition, the theory allows for the assessment of these factors as they may influence the perception, evaluation, and response of an individual at risk for potential symptoms. The environment refers to the context within which a symptom occurs (Dodd et al., 2001). As asserted by Dodd et al. (2001), the environmental domain includes



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Figure 3.2  Revised Symptom Management Conceptual Model. Person Demographic, Psychological, Sociological, Physiological, Developmental

Symptom Experience Symptom Management Strategies Perception of Symptoms

Evaluation of Symptoms

Who? What?

(Delivers) How much?

When?

To Whom?

Where?

Response to Symptoms

How? Why?

Symptom Outcomes

Environment Physical Social Cultural

Emotional Status Health Service Utilization Mortality

Functional Status Symptom Status

Adherence

Self-Care Ability

Costs

Health & Illness Risk Factors Health Status Disease & Injury

Quality of Life Morbidity & Comorbidity

Source: Dodd et al. (2001).

physical, social, and cultural variables. The physical environment may include home, work, and hospital. The social environment includes one’s social support system and interpersonal relationships. Cultural aspects of the environment are those beliefs, values, and practices that are unique to one’s identified ethnic, racial, or religious affiliations. Studies demonstrated that the setting where symptoms were experienced affected the selection of both management strategies and outcomes (Dodd et al., 1999; Humphreys, Lee, Neylan, & Marmar, 1999).

THEORY ANALYSIS Overall, the Symptom Management Theory meets the criterion of internal consistency. Semantic consistency is apparent in the consistent use of terms in each publication of the theory (Dodd et al., 2001; Humphreys et al., 2008; Larson et al., 1994). Although the philosophical basis of the theory was not made explicit by Humphreys et al. (2008), it could be asserted that their conceptualization of the person and of nursing is congruent with a humanistic philosophy. According to Humphreys et al. (2008), symptoms are viewed as subjective in nature and the nurse’s role in symptom management is to attempt to understand symptom experiences and symptom

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management strategies from the patient’s perspective. In addition, the concepts are adequately linked by means of bidirectional, propositional relationships between symptom experience, symptom management, and symptom outcomes, indicating the structural consistency of the theory. The theory meets the criterion of parsimony because the language used in the description of the concepts is clear and concise. Semantic clarity is apparent from the constitutive definitions given for the components of each concept. Although a conceptual distinction was made between symptom perception and symptom evaluation in the first version of the theory (Larson et al., 1994), it can be difficult to distinguish these processes empirically because they can occur simultaneously. However, Dodd et al. (2001), in the revised version of the theory, provided guidance on how these terms could be distinguished. According to these authors: One way of viewing the difference between perception and evaluation is that evaluation is a higher order phenomenon: A person can perceive pain simply by recognizing the sensations, whereas evaluation involves a higher order cognitive process of attaching meaning to a symptom. (Dodd et al., 2001, p. 673) According to Fawcett (2000), the relatively concrete and specific nature of middle range theories implies that their concepts have operational definitions and their propositions can lead to direct propositional testing. It is also implied that empirical indicators are directly related to theories by naming their associated dimensions (Meleis, 2012). Thus, the next question to be considered is related to whether the concepts could be readily operationalized. The Symptom Management Theory identifies the relationships among the core concepts and provides a structure for understanding the connections among their components. Relating to symptom experience, the dimensions describing the components of perception, evaluation, and responses are identified in the theory.

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING A growing body of knowledge is developing from using the Symptom Management Theory. The concepts of the theory (symptom experience, symptom management strategies, and symptom outcomes) have been used as the theoretical basis for a number of studies (presented subsequently) conducted by nurse researchers at the UCSF School of Nursing. A review of these studies revealed considerable empirical support. Relating to symptom experience, two correlational descriptive studies undertaken by Humphreys explored the symptom experiences of battered women. In a 2003 study, Humphreys reported a strong correlation between women’s (n = 50) psychological distress and the frequency and severity of the battering experienced. Humphreys and Lee (2005) sought to explore sleep disturbance in battered women (n = 29) living in transitional housing programs and compared their experiences with women living with children in a secure home (n = 30). Findings showed that women frequently experienced disturbed sleep patterns while living in transitional housing settings. Overall, they took longer to fall asleep (longer than 15 minutes), did not get a full night’s sleep (awake longer than 12% of the night), and slept for 6.5 hours nightly.



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In a prospective descriptive study, Puntillo, Smith, Arai, and Scotts (2008) explored the symptom experiences of high-risk ICU (intensive care unit) patients from the perspectives of specialist nurses (n = 22). In a secondary analysis of responses to openended questions (which formed part of a larger cross-sectional study), Heilemann, Coffey-Love, and Frutos (2004) revealed women’s perceptions of the sources of their depression (n = 107). In a descriptive correlational secondary analysis, Voss (2005) illustrated how the domains of person, health, and environment inherent within the Symptom Management Theory provided the contextual variables for an investigation of the symptom experiences of people with HIV/AIDS (n = 372). Findings highlighted that the symptom of fatigue was higher in African Americans than in other ethnic groups. It was also found that men and women living in poverty, of poor educational status and sociodemographic background, had higher fatigue levels than people from a higher sociodemographic group. Relating to symptom management strategies, Coleman et al. (2006) explored gender differences and use of prayer in the management of HIV/AIDS–related symptoms (n = 448). These researchers found that prayer was used by more men than women to manage nausea (n = 33; 52% vs. n = 30; 48%), depression (n = 55; 90% vs. n = 45; 73%), and anxiety (n = 77; 83% vs. n = 73; 87%), whereas more women used prayer to manage fatigue (n = 54; 74% vs. n = 62; 46%). Studies underpinned by more than one concept of the theory have also been undertaken. Kirksey et al. (2002) utilized two concepts of the theory (symptom experience and symptom management strategies) to underpin their study by involving people suffering from HIV. In a quantitative descriptive study, Hudson, Kirksey, and Holzemer (2004) explored the influence of HIV symptoms experienced on quality of life of women living with HIV (n = 118). Some studies included the three concepts of the Symptom Management Theory in their investigations. For example, Nicholas et al. (2002), in their study, adopted symptom experience, symptom management strategies, and symptom outcomes to form the theoretical basis for a second study involving people with HIV. In a cross-sectional study, Fuller, Welch, Backer, and Rawl (2005) sought to describe the experience, the perceived effectiveness of self-care strategies, and the lifestyle limitations associated with living with constipation among patients with pelvic floor disorders (n = 30). This study was underpinned by the three dimensions of the Symptom Management Theory (Dodd et al., 2001; Humphreys et al., 2008)—­symptom experience, symptom management strategies, and symptom outcomes. Constipation was described as a subjective experience that had a slight effect on their lifestyle. Pertaining to the symptom management strategies adopted to manage constipation, data showed that the most effective strategies used by women included the intake of fiber, consuming more fruit and vegetables, and taking laxatives. In a study focusing on patients receiving cancer treatment, Chou, Dodd, Abrams, and Padilla (2007) explored the cancer symptom experiences, self-care strategies, and quality of life among Chinese Americans (n = 25) during outpatient chemotherapy for a variety of cancers. This research concluded that although multiple symptoms were experienced by participants, a limited number of self-care strategies were used by patients to manage symptoms. Lee, Dodd, Dibble, and Abrams (2008), in a secondary analysis (based on the findings of a longitudinal, single-blinded, three-armed randomized trial), investigated the relationship between nausea and exercise during and after adjunct cancer treatment for breast cancer (n = 112). The study focused on nausea as a symptom, exercise as a management strategy, and nausea intensity as an

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outcome. Conclusions suggested that patients with breast cancer, who performed a moderate level of aerobic exercise during adjunct cancer treatment, experienced less intensive nausea on treatment completion. More recently, research underpinned by the Symptom Management Theory focused on the construct symptom clusters. Dodd, Cho, Cooper, and Miaskowski (2010), in a secondary analysis, sought to determine the number of patient subgroups based on a specific symptom cluster (pain, fatigue, sleep disturbance, and depression) in a sample of women (n = 112) receiving chemotherapy with or without radiation for breast cancer. Subgroups were formulated from the results of a cluster analysis of symptom severity scores (low, mild moderate, and high). Symptom severity was assessed at three time intervals (baseline, end of treatment, 1 year after completion of treatment). Findings showed that all of the women experienced one or more symptoms 6 months following completion of their cancer treatment. Additionally, a recent publication (Landers, Savage, & McCarthy, 2012) demonstrated how key concepts and their components of perception, evaluation, responses, and self-care strategies were used in the construction of three semistructured questions included in the questionnaire for the current study—patients’ experiences of bowel symptom and self-care strategies following sphincter-saving surgery for rectal cancer—and in the development of predetermined categories for the analysis of these data. Written commentary was retrieved from 122 patients. Questions sought to reveal the bowel symptoms that were most problematic for patients (symptom perception), the effects of bowel symptoms on their daily lives (symptom evaluation and response), and the effectiveness of self-care strategies adopted to manage symptoms. This section demonstrates that the Symptom Management Theory has been used to guide a range of studies using one or more of its core concepts. This evidence serves to support the conceptual claims made in the theory and illustrates the usefulness of the theory in providing a conceptual basis for nursing research. Additionally, findings also help to substantiate the hypothesized relationships made in the theory. However, further research is necessary investigating the relationship among all three concepts (symptom experiences, symptom management strategies, and symptom outcomes) in one study.

USE OF THE THEORY IN THIS RESEARCH Following a review of the conceptual and theoretical literature on symptom experience and symptom management, it was decided that the Symptom Management Theory offered the most comprehensive framework to guide the research. The Symptom Management Theory, in part, meets the criterion of testability for middle range theories. The core concepts—symptom experience, symptom management strategies, and symptom outcomes and their components—are identified and described in the theory. Initially, these concepts (and their components) provided a focus for the literature review. The concept of symptom experience provided a framework for a review of studies that focused on the components of symptom perception, symptom evaluation, and symptom response of patients’ symptom experiences across the gastrointestinal illness trajectory, including colorectal cancer. The concept of symptom management strategies guided a review of studies that focused on the self-care strategies used by patients experiencing and managing chronic bowel symptoms in chronic conditions and following surgery for colorectal cancer. The third concept of



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the Symptom Management Theory, symptom outcomes (Figures 3.1 and 3.2), was not a concept under study in the current investigation. The rationale for choosing the Symptom Management Theory (Dodd et  al., 2001; Humphreys et al., 2008) to guide the operationalization of the current research was based on Fawcett’s (1999) and adapted from Bredow’s (2004) evaluative criteria (Table 3.1). Initially, the question “Does the theory fit the research that you wish to do?” was considered when deciding on a framework to underpin a study on patients’ experiences of bowel symptom and self-care strategies following sphincter-saving surgery for rectal cancer. The Symptom Management Theory is broadly based and thus relates to and provides a focus for research questions and research hypotheses. In this regard, the theory addresses primary questions in terms of describing patients’ experiences of bowel symptom and selfcare strategies following sphincter-saving surgery for rectal cancer, and secondary questions relating to the relationship between patients’ experiences of bowel symptom and self-care strategies following surgery. Thus, the assumptions of the theory are congruent with the assumptions that are made for the research, in that: (a) there is a directional relationship between symptom experience and self-care strategies; (b) symptoms are subjective in nature; and (c) nurses should not focus just on the outcomes of symptom management but seek to understand the total symptom experience from the person’s perspective. In order to operationalize the dimensions relating to symptom experience, elements from the Common-Sense Model of Self-Regulation (CSMSR) (Leventhal, Brissette, & Leventhal, 2003; Leventhal & Diefenbach, 1991; Leventhal, Nerenz, ­ & Steele, 1984) were adopted. In order to operationalize the dimension symptom awareness (perception), the identity element from the CSMSR (Leventhal & Diefenbach, 1991; Leventhal et al., 1984) was adopted. Thus, in the current study, perception referred to patients’ awareness of bowel symptom occurrence in terms of symptom identity and symptom frequency. (The relationship between bowel symptom frequency and the self-care strategies used was not estimated.) The conceptual framework (Figure 3.3) developed for the study presents a synthesis of theoretical- and empirical-based literature that provides for an exploration of the self-care strategies used by patients following sphincter-saving surgery for rectal cancer. It also demonstrates the potential relationship between these strategies and the components of symptom experience (symptom perception, symptom evaluation, and symptom response). The conceptual framework also provided the basis for the presentation and discussion of study findings. The second component, symptom evaluation, refers to the judgment individuals make about their symptoms based on the following dimensions: cause, severity, effects, temporality, and their views on the treatability of the symptoms experienced (Dodd et al., 2001; Larson et al., 1994). Based on the CSMSR (Leventhal & Diefenbach, 1991; Leventhal et al., 1984), cause was operationalized as both internal and external causes. Elements from the 2003 version of the CSMSR (Leventhal et al., 2003) guided the operationalization of the remaining dimensions relating to evaluation. The term consequence was adopted to operationalize severity and effects, and timeline was adopted to operationalize temporality. Timeline was considered in the context of both symptom duration and the cyclical nature of the symptoms experienced (Leventhal et al., 2003). The cyclical component of this element had relevance for the current study because the bowel symptoms experienced by patients were often recurrent and unpredictable. Treatability was operationalized in terms

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Table 3.1 Evaluative Criteria and Use of Symptom Management Theory Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

The theory focuses on the relationship between symptom experience and self-care strategies and thus fits the current study, which focuses on the relationship between patients’ bowel symptom experience and self-care strategies following sphincter-saving surgery for rectal cancer.

2.

Is it readily operationalized?

Yes, but in order to operationalize five of the theory concepts—(1) symptom awareness, (2) severity, (3) effects, (4) temporality, and (5) treatability of the Symptom Management Theory—three ­elements (iden­ tity for symptom awareness, timeline for temporality, and consequences for severity and effects) were adopted from the ­Common-Sense Model of Self-Regulation (CSMSR) (Leventhal et al., 2003).

3.

How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it relates?

The theory has been used to describe women’s experiences of being battered (Humphreys, 2003; Humphreys & Lee, 2005). Components from the three dimensions of the theory (symptom experience, symptom management strategies, and symptom status outcomes) have been used in studies exploring symptom experience, self-care strategies, and quality of life in patients undergoing chemotherapy for a variety of cancers (Chou et al., 2007) and studies evaluating the relationship between nausea and exercise during and after adjunct treatment for breast cancer (Lee et al., 2008).

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

The theory relates to and addresses the research hypotheses in its description and explanation of the relationship between patients’ bowel symptom experiences in terms of their perceptions, evaluations, and responses and the number of self-care strategies used to manage their symptoms.

5.

Does the theory flow from the research question?

The question has the potential to expand knowledge relating to symptom experience and self-care strategies in patients following sphincter-saving surgery for rectal cancer, as well as the relationship between symptom experience and self-care strategies in these patients. Therefore, the theory guided the development of the research question and hypotheses.

6.

Does the theory address the primary and secondary research questions?

The theory addresses the primary and secondary research ­questions—to describe patients’ bowel symptom experiences (perception, evaluation, response) following sphincter-saving surgery, and to investigate their relationship to the self-care strategies used by patients to manage these symptoms.

7.

Are the assumptions congruent with the assumptions that are made for research?

The assumptions are congruent with the assumptions that are made for the research in that: (a) there is a directional relationship between symptom experience and self-care strategies; (b) symptoms are subjective in nature; and (c) nurses should not focus just on the outcomes of symptom management but seek to understand the total symptom experience from the patients’ perspective. (continued)



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Table 3.1 Evaluative Criteria and Use of Symptom Management Theory (continued) Questions for evaluation

Responses to questions

8.

Is the theory oriented to outcomes that are critical to patients?

The theory is oriented to outcomes that are critical to patients. It allows for patients’ individual experiences of symptoms to be ascertained, and the relationship between these experiences and the self-care strategies adopted to manage their symptoms.

9.

Are tools available to test relationships of the theory or do they need to be developed?

In the current study, the Illness Perception Questionnaire (IPQ); the Revised Illness Perception Questionnaire (IPQ-R), based on Leventhal and colleagues’ (2003) CSMSR; and the ­Difficulties of Life Scale (Tanaka et al., 2003) were adapted and used to test the relationship between patients’ bowel symptom experiences and self-care strategies following sphincter-­saving surgery for rectal cancer.

Source: Fawcett (1999, 2005).

of patients’ beliefs about their control (personal control) over the symptoms and the anticipated and expected responsiveness of the symptoms to self-treatment (treatment control). In this regard, symptom evaluation conveys experiential understanding, which enables individuals to give meaning to their experiences of the bowel symptoms and equips them to take action. This conceptualization provides the basis for an understanding of the various responses of patients to the bowel symptoms experienced. The third component, symptom responses, includes psychological, social, and physiological responses. Psychological responses concern affective changes such as fear or worry. Based on a review of the literature, psychological responses were considered to be depression, anger, worry, anxiousness, fear, and embarrassment. The emotional representation element of the CSMSR (Leventhal et al., 2003) was adopted to operationalize psychological responses in the current study. Social responses take into account the social alterations made as a result of the bowel symptoms experienced, such as social restriction and social withdrawal/social isolation. Physiological responses may include a patient’s response to a perceived threat associated with alterations in functioning, such as fecal soiling or extreme tiredness because of bowel symptoms. This aspect of the conceptual framework proposes that people act in response to the symptoms experienced, and these actions provide information not only on the symptoms experienced but also on their resources and ability to control and maintain their physical, psychological, and social integrity (Dodd et al., 2001). The Symptom Management Theory posits that the goal of symptom management is to avert or delay a negative outcome through biomedical, professional, and self-care strategies (Dodd et al., 2001; Humphreys et al., 2008; Larson et al., 1994). These authors also propose that symptom management is conceptualized as a dynamic process often dictating changes in strategies over time. The inappropriateness of some strategies used may result in the need for techniques to be changed or modified to ensure optimum outcomes. In the current study, self-care strategies were conceptualized as the self-care strategies used by patients to manage the bowel symptoms experienced following surgery. Based on the findings of previous studies,

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Independent variables Dependent variable

Demographic Characteristics

Characteristics Related to Treatment

Bowel Symptom Perceptions

Bowel Symptom Evaluations Causes—Internal & External

Consequences (Severity/Effects)

Bowel Symptom Identity (Symptom Awareness)

Timeline Acute/Chronic/Cyclical (Temporality)

Bowel Symptom Responses Psychological Physiological

Control Personal/Treatment (Treatability)

Self-Care Strategies—Functional, Social-Related, Activity-Related

Adapted from Humphrey et al. (2008), Leventhal et al. (2003), Leventhal & Diefenbach (1991), Leventhal et al. (1984).

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Part II  Theories Applied to Research

Figure 3.3  Conceptual Framework for the study adapted from the Symptom Management Theory and ­components from the Common-Sense Model of Self-Regulation for the operationalization of concepts.



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self-care methods for managing bowel symptoms can be grouped into three categories: functional strategies (e.g., taking medication), social activity-related procedures (the wearing of protective clothing), and alternative techniques (e.g., complementary therapy). The criterion of empirical adequacy for middle range theories is met when instruments have been developed to observe the theory concepts, and statistical techniques have been designed to measure the assertions made by the proposition(s). However, the theory has not been used to date as the basis for the development of research instruments to assist investigators in using the theory. Research tools focusing on symptom experiences across a number of illnesses were reviewed with regard to their appropriateness for the current study. In addition, instruments were reviewed, which measured the self-care strategies adopted by patients who were suffering from one bowel symptom only or for populations diagnosed with chronic bowel disease. In the current study, modified versions of the Illness Perception Questionnaire (IPQ; Weinman, Petrie, Moss-Morris, & Horne, 1996), the Revised Illness Perception Questionnaire (IPQ-R; Moss-Morris et al., 2002), and the Difficulties of Life Scale 18-item ordinal scale (Tanaka, Miyawaki, & Kaxuma, 2003) were used to measure patients’ bowel symptoms experienced following sphincter-saving surgery for rectal cancer. The benefits of the IPQ and IPQ-R for the current study include the fact that they are based on the CSMSR (Leventhal et al., 2003; Leventhal & Diefenbach, 1991; Leventhal et al., 1984), and that it provided for the operational definitions of the concepts of symptom perception and symptom evaluation. Only one instrument was retrieved that measured the self-care strategies patients used following sphincter-saving surgery for rectal cancer. However, this instrument focused on the self-care strategies following the implementation of an educational program, rather than on the self-care strategies chosen by patients themselves to manage their bowel symptoms. Consequently, a researcher-developed measure based on a review of the literature on the self-care strategies employed to manage chronic bowel symptoms and the bowel symptoms experienced in chronic bowel disease was used. It could also be proposed that the theory is oriented to outcomes that are critical to patients. The significance of symptom management in health care arose from the increasing awareness of the limitations of medical and surgical interventions in curing the cause of disease and related symptoms, and from an increased emphasis on better outcomes for these patients (Fu, Lemone, & McDaniel, 2004). Concurrently, there is also an awareness of the consequences of medical and surgical interventions in disease treatment. Whereas it is documented that new and less invasive surgical treatments increase survival rates (Haward, Morris, Monson, Johnson, & Forman, 2005), patients can experience a number of short- and long-term symptoms that they have to live with on a daily basis following such treatments (Desnoo & Faithfull, 2006). Although health care professionals can be expected to support patients in managing these symptoms, the management of symptoms and the resultant effects of treatments frequently become the responsibility of individual patients (Dodd et al., 2001). The components of the theory allow for patients’ individual experiences of symptoms to be ascertained, and the relationship between these experiences and the self-care strategies adopted to manage their symptoms and the theory flow from the research question.

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RECOMMENDATIONS FOR FURTHER RESEARCH Based on the current theoretical assertions regarding symptom clusters (Dodd et al., 2001; Humphreys et al., 2008), further research should now build on the findings of the current study, which identified symptom patterns in patients following sphincter-saving surgery. An exploration of symptom cluster is important to determine whether relationships exist between bowel symptoms experienced, since the alleviation of one bowel symptom might help to ease the effect of others. The question has potential to expand knowledge relating to symptom experience and self-care strategies in patients following sphincter surgery for rectal cancer, and the relationship between symptom experience and self-care strategies in these patients.

SUMMARY The purpose of this chapter is first to present an analysis and evaluation of the Symptom Management Theory, based on publications on the development of the theory. Fawcett’s (2005) framework for the analysis and evaluation of theories of nursing allowed for both a comprehensive and systematic assessment of the Symptom Management Theory. The criteria identified by Fawcett (1999) and Bredow (2004) for choosing a theory to guide a research study were then applied. This analysis demonstrated that the Symptom Management Theory provided a comprehensive guide toward understanding of patients’ bowel symptom experiences and of the self-care strategies used to manage symptoms following sphincter-saving surgery for rectal cancer. The Symptom Management Theory takes cognizance of the components of symptom experience (perception, evaluation, and response). The inclusion of these components in the current study permits both a systematic and a holistic investigation of the variables that influence the selfcare strategies that patients use to manage bowel symptoms following sphincter-saving surgery for rectal cancer. In particular, the current study helps to support the conceptual claims made in the theory, as well as illustrate the suitability of the theory in providing a conceptual basis for nursing research. The concepts (and their components) are broadly based and are useful in providing a structure for the literature review. The theory also provides a focus for research questions and hypotheses and aids in the presentation and discussion of findings. However, in order to fully meet the criterion of empirical adequacy in middle range theories, it is important now that an instrument based on the Symptom Management Theory be developed to assist researchers in using the theory. By focusing on symptom management from the perspective of the individual, Humphreys et al. (2008) have made a considerable and noteworthy contribution to the development of contemporary disciplinary nursing knowledge. This focus has significant meaning in a climate of care in which the management of symptoms and the resultant effects of treatments frequently are becoming the responsibility of individual patients.

References Bredow, T. S. (2004). Analysis, evaluation and selection of a middle range nursing theory. In S. J. Peterson & T. S. Bredow (Eds.), Middle range theories: Application to nursing research (pp. 42–56). Philadelphia, PA: Lippincott Williams & Wilkins. Chou, F. Y., Dodd, M., Abrams, D., & Padilla, G. (2007). Symptoms, self-care, and quality of life of Chinese American patients with cancer. Oncology Nursing Forum, 34(6), 1162–1167.



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Coleman, C. L., Holzemer, W. L., Eller, L. S., Corless, I., Reynolds, N., Nokes, K. M., & Hamilton, M. J. (2006). Gender differences in use of prayer as a self-care strategy form managing symptoms in African Americans with HIV/AIDS. The Journal of the Association of Nurses in AIDS Care, 17(4), 16–23. Desnoo, L., & Faithfull, S. (2006). A qualitative study of anterior resection syndrome: The experiences of cancer survivors who had undergone resection surgery. European Journal of Cancer Care, 15(3), 244–251. Dodd, M. J., Cho, M. H., Cooper, B. A., & Miaskowski, C. (2010). The effect of symptom clusters on functional status and quality of life with breast cancer. European Journal of Oncology Nursing, 14(2), 101–110. Dodd, M. J., Jansen, S., Facione, N., Faucett, J., Froelicher, E. S., Humphreys, J., & Taylor, D. (2001). Advancing the science of symptom management. Journal of Advanced Nursing, 33(50), 668–678. Dodd, M. J., Miaskowski, C., Shiba, G., Dibble, S., Greenspan, D., Paul, S., & Larson, P. (1999). Risk factors for chemotherapy-induced oral mucositis: Dental appliances, oral hygiene, previous oral lesions and history of smoking. Cancer Investigations, 17(4), 278–284. Facione, N. C., & Dodd, M. J. (1995). Women’s narratives of helpseeking for breast cancer. Cancer Practice, 3(4), 219–225. Fawcett, J. (1999). The relationship of theory and research. Philadelphia, PA: F. A. Davis. Fawcett, J. (2000). The analysis and evaluation of contemporary nursing knowledge: Nursing models and theories. Philadelphia, PA: F. A. Davis. Fawcett, J. (2005). Criteria for evaluation of theory. Nursing Science Quarterly, 18(2), 131–135. Fu, M. R., Lemone, P., & McDaniel, R. W. (2004). An integrated approach to an analysis of symptom management in cancer patients. Oncology Nursing Forum, 31(1), 65–70. Fuller, E., Welch, J., Backer, J., & Rawl, S. (2005). Symptom experience of chronically constipated women with pelvic floor disorders. Clinical Nurse Specialist, 19(1), 34–40. Haward, R. A., Morris, E., Monson, J. R. T., Johnson, C., & Forman, D. (2005). The long term survival of rectal cancer patients following abdomino-perineal and sphincter-saving surgery: Results of a population-based observational study. The Journal of Cancer Surgery, 31(1), 22–28. Heilemann, M. V., Coffey-Love, M., & Frutos, L. (2004). Perceived reasons for depression among low income women of Mexican descent. Archives of Psychiatric Nursing, 18(5), 185–192. Hudson, A. L., Kirksey, K., & Holzemer, W. (2004). The influences of symptoms on quality of life among HIV-infected women. Western Journal of Nursing Research, 26(1), 9–23. Humphreys, J. (2003). Resilience in sheltered battered women. Issues in Mental Health Nursing, 24(2), 137–152. Humphreys, J., & Lee, K. A. (2005). Sleep disturbance in battered women living in transitional housing. Issues in Mental Health Nursing, 26(7), 771–780. Humphreys, J., Lee, K. A., Carrieri-Kohlman, V., Puntiollo, K., Faucett, J., Janson, S., & the UCSF School of Nursing Symptom Management Faculty Group. (2008). The theory of symptom management. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing (2nd ed., pp. 145–158). New York, NY: Springer Publishing Company. Humphreys, J. C., Lee, K., Neylan, T. C., & Marmar, C. (1999). Sleep patterns of sheltered battered women. Image: The Journal of Nursing Scholarship, 31(2), 139–143. Kirksey, K. M., Goodroad, B. K., Kemppainen, J. K., Holzemer, W. L., Bunch, E. H., & Bain, C. (2002). Gender differences in use of prayer as a self-care strategy form managing symptoms in African Americans with HIV/AIDS. The Complementary Therapy Use in People With AIDS, 20(3), 264–278.

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Part II  Theories Applied to Research Landers, M., Savage, E., & McCarthy, G. (2012). Bowel symptom experiences and management following sphincter-saving surgery for rectal cancer: A qualitative perspective. European Journal of Oncology Nursing, 16(3), 293–300. Larson, P. J., Carrieri-Kohlman, V., Dodd, M. J., Douglas, M., Faucett, J., Froelicher, E. S., & Underwood, P. (1994). A model for symptom management. Image: Journal of Nursing Scholarship, 26(4), 272–276. Lee, J., Dodd, M. J., Dibble, S. L., & Abrams, D. I. (2008). Nausea at the end of adjunct cancer treatment in relation to exercise during treatment in patients with breast cancer. Oncology Nursing Forum, 35(5), 830–835. Leventhal, H., Brissette, I., & Leventhal, E. A. (2003). The Common-Sense Model of Self-­ Regulation of health and illness. In L. D. Cameron & H. Leventhal (Eds.), The self-regulation of health and illness behavior (pp. 42–64). London, UK: Routledge. Leventhal, H., & Diefenbach, M. (1991). The active side of illness cognition. In J. A. Skelton & R. T. Croyle (Eds.), Mental representation in health and illness (pp. 247–272). New York, NY: Springer Verlag. Leventhal, H., Nerenz, D. R., & Steele, D. J. (1984). Illness representation and coping with health threats. In A. Baum, S. E. Taylor, & J. E. Singer (Eds.), Medical handbook of psychology and health (Vol. IV, pp. 219–252). Hillside, NJ: Erlbaum. Meleis, A. I. (2012). Theoretical nursing: Development and progress. Philadelphia, PA: Lippincott Williams & Wilkins. Moss-Morris, R., Weinman, J., Petrie, K. J., Horne, R., Cameron, L. D., & Buick, D. (2002). The Revised Illness Perception Questionnaire (IPQ-R). Psychology and Health, 17 (1), 1–16. Nicholas, P. K., Kemppainen, J. K., Holzemer, W. L., Nokes, K. M., Eller, S., Coreless, L. B., & Goodroad, B. K. (2002). Self-care management for neuropathy in HIV disease. AIDS Care, 14(6), 763–771. Puntello, A., Smith, D., Arai, S., & Scotts, N. (2008). Critical care nurses provide their perspectives of patients’ symptoms in intensive care units. Heart and Lung, 37(6), 466–475. Tanaka, M., Miyawaki, I., & Kaxuma, K. (2003). A study of the relationship between selfevaluation of physical condition and perception of difficulties of life in ulcerative colitis patients. Gastroenterology Nursing, 26(3), 115–124. Voss, J. G. (2005). Predicators and correlates of fatigue in HIV/AIDS. Journal of Pain and Symptom Management, 29(20), 173–184. Weinman, J., Petrie, K. J., Moss-Morris, R., & Horne, R. (1996). The illness perception questionnaire: A new method for assessing the cognitive representation of illness. Psychology and Health, 11(3), 431–445.

chapter 4

Transitions Theory Alice Coffey

Transitions Theory is a middle range theory that has been in development since the 1960s. Theorist Afaf Ibrahim Meleis is a nurse academic with a background in nursing, sociology, symbolic interactionism, and role theory. The theory evolved from concept to theory over three decades of research. The word transition is derived from the Latin verb transpire, meaning to go across, which revolves around the notion of change and movement (Chick & Meleis, 1986). Transitions have been studied in the contemporary literature of many disciplines (Wilkins & Woodgate, 2006). It is a familiar concept in developmental theories; for example, psychologists such as Erikson identified eight stages of psychological development and the processes of adaptation to transition. The emergence of transition as a nursing concern evolved through research supporting the centrality of the concept in nursing.

BASIC DESCRIPTION OF THE THEORY The importance of transition as a central concept in nursing was first proposed by Meleis in 1975. Subsequently, a concept analysis of transition conducted by Chick and Meleis (1986, p. 240) defined transition as a “process of passage from one life phase, condition or status to another.” An important characteristic of transition, according to Chick and Meleis, is that it is essentially positive: “completion of a transition implies that the person has reached a period of greater stability relative to what has gone before” (1986, p. 240). Consequences of transition may be the disruption of connections or linkages, and differences in perception of the transition, which may influence reactions and responses. Transition is a personal phenomenon, related to definitions and redefinitions of self and situation; therefore, the level of awareness of the transition is important. In their concept analysis, Chick and Meleis proposed that transitions are not experienced uniformly by people, even when the circumstances are similar; however, there are common attributes. The general structure consists of three phases: entry, passage, and exit. Dimensions of transitions may be single or multiple, minor disruption or major disruption, temporary or permanent, desired or undesired (Chick & Meleis, 1986). Meleis (1991) proposed that transitions had profound health-related effects on

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patients and clients. She described transitions in the context of health, as changes in health status, role relations, expectations, or abilities that may require the person to acquire new knowledge, to alter behavior, and therefore to change the definition of self (Meleis, 1991). Further development of Meleis’s Transitions Theory resulted in the conceptualization of a nursing model of transitions (Schumacher & Meleis, 1994). This model incorporated subjective, behavioral, and interpersonal dimensions of health and a holistic understanding of conditions that influence the transitions (Schumacher & Meleis, 1994). An extensive review of nursing literature conducted by Schumacher and Meleis (1994) identified several types of transition that nurses deal with: ●●

Individual developmental—adolescence, becoming aware of sexuality, and going into midlife

●●

Family developmental—mother–daughter relationships and parenthood

●●

Situational—educational transitions, professional role change, relocation to nursing home, and immigration

●●

Organizational—changes in leadership, new policy implementation, changes in nursing and in communities

●●

Health/illness—the recovery process, hospital discharge, and diagnosis of chronic illness

Meleis and Trangenstein (1994) suggested that although other disciplines also focus on transitions, the unique contribution of nursing is its process orientation and goal of well-being. In recognition of the importance of transitions in the health and wellness of individuals, and to assist nurses in facilitating the transition experience, Meleis and colleagues developed their middle range theory of transitions (Meleis, Sawyer, Im, Messias, & Schumacher, 2000) as a basis for theory development.

CORE CONCEPTS Through collaborative research, a theoretical framework (Meleis, 2010) emerged that consisted of core concepts: 1. Nature of the transition (types and patterns of transitions and properties of transition experiences) 2. Transition conditions (personal, community, and society) that can be facilitators and inhibitors of transition 3. Patterns of response (process and outcome indicators) 4. Nursing therapeutics Despite the diversity of transitions, according to Chick and Meleis (1986) there are some commonalities. Universal properties were identified, such as that transitions occur over time and that the process involves flow, development, and change (Schumacher & Meleis, 1994). Within the concept named nature of the transition, the subconcepts are type of transition pattern and properties. Transitions are, however,



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complex processes involving different patterns and properties. Types of transitions include developmental, health and illness, situational, and organizational. The pattern of transition, according to Meleis, is that single or multiple transitions can occur at a given time and may be related or unrelated. For example, the pattern of transition may be described as sequential, where one transition leads to another (e.g., an older person experiencing illness who consequentially experiences loss of functional ability). Simultaneous transitions, on the other hand, are clusters of related or unrelated transitions at the same time. The properties of transition: In their original work, Chick and Meleis (1986) proposed that properties of transition were that it occurred over time, involved movement from one state to another, and also involved change. During transition, changes can occur in identity, roles, relationships, abilities, and patterns of behavior (­Schumacher & Meleis, 1994). On further development of their Transitions Theory, Meleis et al. (2000) identified awareness, engagement, change and difference, time­ span, critical points, and events as essential and interrelated properties of transition experiences. Awareness, according to Meleis et al. (2000), is related to recognition of the experience and is important to successful transition. Lack of awareness signifies that the individual may not be ready for the transition. Change and difference are essential properties of a transition because all transitions involve change. Transition conditions were described by Meleis et al. (2000) as the personal and environmental conditions that facilitate or inhibit progress toward achieving a healthy transition. According to Meleis et al. (2000), patients’ perceptions of their health/illness situation are influenced by, and in turn influence, the conditions (personal and environmental) under which a transition occurs. Personal factors that may influence the transition are meanings, expectations, preparation, and knowledge. Environmental factors are community resources and societal conditions. According to Meleis et al. (2000), the meanings attributed by people to the transition itself and its process may facilitate or hinder healthy transitions. Meanings refer to the subjective appraisal of an anticipated event and the evaluation of its likely effect on one’s life. Cultural beliefs and attitudes may also facilitate or hinder healthy transition. Meleis et al. (2000) contend that when stigma is attached to a transition experience, the personal expression of emotion related to that transition can be inhibited. An example provided by Meleis (2010) was the emotional state of an individual going through menopause. If a cultural stigma exists with regard to a transition, this could impact on the process and outcomes of the transition. The socioeconomic status of individuals can be a facilitator or inhibitor to successful transition and result in people experiencing psychological symptoms during a transition (Meleis et al., 2000). Anticipatory preparation and knowledge facilitate the transition experience, where lack of preparation is an inhibitor (Meleis et al., 2000). Community resources and societal conditions, according to Meleis et al., are transition conditions that can inhibit or facilitate a healthy transition. Community resources were described as the availability of support from family, friends, and services; relevant information; role models; and advice (Meleis et al., 2000). Societal conditions can be an inhibitor to a healthy transition if, for example, the transitional event is stigmatized or stereotyped. Marginalization of people in society can result in their being neglected or ignored (Meleis, 2010). A healthy transition, according to Meleis et al. (2000), is characterized by both process and outcome indicators. The consequences of a transition, therefore, may occur at any point in the transition.

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Process Indicators The process indicators inherent in healthy transitions, according to Meleis et al. (2000), are feeling connected and interacting, location and being situated, and developing confidence and coping. Feeling connected and interacting with family, friends, and other supports are prominent themes, asserted by Meleis et al. (2000), in patterns of response to transitions. Important sources of connectedness during and following transition are social networks and other services in the community. Postdischarge, connecting with health professionals and other sources of support in the community could provide comfort and continuity of care. Location and being situated are important to most transitions. One of the characteristics of a transition is the creation of new meanings and perceptions (Meleis, 2010). Sometimes a transition can result in new living situations, and, as maintained by Meleis (2010), people need to situate themselves in terms of time, space, and relationships. In the trajectory of a transition, the dimensions of developing confidence and coping are progressive from one point to the next. According to Meleis (2010), one reflection of the response to the transition and its processes is the extent to which there is a pattern indicating that the individual is experiencing increased confidence and coping.

Outcome Indicators Two outcome indicators of healthy transitions were identified by Meleis et al. (2000): mastery and fluid integrative identities. These, reported by Meleis (2010), reflect healthy outcomes of a transition. Some transitions result in new situations or environments; the extent to which an individual demonstrates mastery of new skills and behaviors needed to manage this transition signifies successful completion of the transition. The determination of whether a transition is complete, however, depends on the type of change or event (Meleis, 2010). If outcomes of a transition are considered too soon, they may be process indicators; if examined too late, outcomes may be related to other life events. Mastery is therefore unlikely to be seen early in the transition experience. Transition experiences are not one-dimensional; rather, each transition experience is characterized by its own uniqueness, complexities, and multidimensions (Meleis, 2010). Understanding the properties and conditions inherent in a transitions process leads to the development of nursing therapeutics that promote healthy responses. The goal of nursing therapeutics is to facilitate healthy transition processes, to decrease unhealthy transitions, and to support positive process indicators (Meleis & Trangenstein, 1994). Continuous assessment by the nurse takes into account the multiple patterns of transition that can often occur. Meleis suggests that the nurse practicing within a transition perspective should conduct assessment of the process indicators at different critical points. This would provide a means of tracking the patient’s progress through the transition, allowing the nurse to identify situations in which there are deviations from the norm (Meleis, 2010). Meleis also identifies the nursing therapeutic of role supplementation, defined as the process of bringing into awareness the behaviors, sentiments, sensations, and goals involved in a given role (Meleis, 2010). This involves facilitating new knowledge through role-modeling, support, and revision of skills and capabilities (­Schumacher, Jones, & Meleis, 1999).



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A further nursing therapeutic is the creation of a healthy environment. In this instance, environment is broadly defined as a person’s physical, social, political, and cultural surroundings. The nurse’s role is to work with patient and family to create a healthy environment to meet their needs and to promote dignity and personal integrity. For persons in transition, the mobilization of resources is an important aspect of nursing practice because previously developed resources may no longer be adequate (Schumacher et al., 1999). These resources include personal, family, and community resources.

RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS There is congruence, stated by Chick and Meleis (1986), between the concept of transition and nursing theories in that it has the potential to be accommodating to, and to be accommodated by, the various theoretical schemes. Defining the nursing mission and identifying the central focus of nursing have been advocated by nursing theorists. According to Meleis (2010, p. 66), “what is needed for substantive knowledge development in nursing is an organising concept that allows for a variety of viewpoints and theories within the discipline of nursing and such a concept should not be culturally bound.” Meleis (2010) submits that Transitions Theory fulfills these criteria. Support for transition as a focus of nursing was provided in an extensive review of nursing literature between 1986 and 1992, in which the word transition was used in 310 papers (Schumacher & Meleis, 2010). In the review, three indicators of successful transition were identified: emotional well-being, mastery, and well-being of relationships. According to Meleis, nursing’s unique contribution is its goal of a sense of well-being. Hence, she described nursing as “facilitating transitions to enhance a sense of well-being” (Meleis, 2010, p. 68). To examine the relationship of Transitions Theory to the metaparadigm of nursing, Fawcett’s (1984) articulation of four nursing metaparadigm concepts (person, health, environment, and nursing) is used as an organizing framework. In nursing theory, human beings are considered in terms of their physiological, psychological, social, spiritual, and cultural selves. In Meleis’s theory of transition, these dimensions of the person are in focus. In the concept of transition conditions, Meleis et al. proposes that persons’ perceptions of their transitions are influenced by, and in turn influence, the personal and environmental conditions under which a transition occurs. Personal factors that may influence the transition are meanings, expectations, preparation, and knowledge. Meanings refer to the subjective appraisal of an anticipated event. Understanding and recognition of their experiences can be influenced by subjective appraisal of a situation or individuals’ psychological functions. Meanings can also affect patients’ realistic expectations of self and physical abilities. Stress can be caused by not knowing what to expect relevant to the transition; and incongruity can occur between the preparation, expectations, and knowledge of self and others (Meleis et al., 2000). In addition, according to Schumacher et al. (1999), a suboptimal level of functioning suggests an unhealthy transition process. Meleis et al. (2000) contend that when stigma is attached to a transition experience, the personal expression of emotion related to that transition can be inhibited. Thus, cultural stigma with regard to a transition could impact on the process and outcomes of the transition. Although the explicit spiritual dimension of the person is not included

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within this theory, in her concept of the nature of the transition Meleis incorporates the dimension “properties” of the transition that include identity, roles, relationships, abilities, and patterns of behavior (Schumacher & Meleis, 1994). On further development of their theory, Meleis et al. identified awareness and engagement as essential and interrelated properties of transition experiences. Awareness, asserted by Meleis et al. (2000), is related to recognition of the experience and is important to successful transition. Lack of awareness signifies that the individual may not be ready for the transition. The concept of environment of nursing comprises all the internal and external factors that act on human beings and affect their behavior and development. These include psychological, spiritual, social, physical, and cultural environment and the context in which nursing care is provided. In the concept of transition conditions within the theory of transition, the environment is conceptualized as community and societal dimensions. The community dimension is articulated as resources and conditions that facilitate or inhibit the transition. Resources include support, information, and living conditions. Society itself, according to Meleis, may facilitate or inhibit transitions. For example, stigma, stereotyping, or marginalization may be inhibiting factors. The concept of health refers to an individual’s physical, mental, and social wellbeing. Health is a phenomenon of central interest to nursing. In Meleis’s theory of transition, health is conceptualized within the health/illness transition, one of the typology of transitions relevant to nursing. As stated by Meleis, multiple types of transition can occur simultaneously and can be interrelated (e.g., health/illness, situational, developmental). Nurses need to consider the pattern of all significant transitions and not just focus on health/illness. In this theory, Meleis also identifies indicators of health that appear relevant to all transitions: 1. Subjective well-being (e.g., coping, a sense of personal dignity, managing emotion, role satisfaction, growth, self-esteem, and empowerment). In the trajectory of a transition, the dimensions of developing confidence and coping are progressive from one point to the next (Meleis, 2010). 2. Role mastery, which denotes achievement of performance, comfort in new situations, competence, knowledge, and skills. These indicators of health are of specific interest to nurses. 3. Well-being of relationships in terms of family and integration in social networks and community. Transitions are of distinct interest to nurses because of their holistic consequences to health. Nursing therapeutic interventions, according to Transition Theory, are applicable in transitions because they are aimed at restoring and promoting health and assisting persons to create conditions conducive to health. The International Council of Nurses (ICN) in its definition of nursing states that “nursing . . . encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles” (ICN, 2010). The concept of nursing in the Transition Theory is articulated as nursing therapeutics. According to the theory, nursing therapeutics facilitate healthy transition processes, decrease unhealthy transitions, and support positive process indicators



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(Meleis & Trangenstein, 1994). Understanding the properties and conditions inherent in a transitions process leads to the development of nursing therapeutics that promote healthy responses. The nursing therapeutics described by Meleis (2010) incorporate nursing assessment, role supplementation, creating a healthy environment, and mobilizing resources.

Nursing Assessment Continuous assessment by the nurse takes into account the multiple patterns of transition that can often occur for older adults. The nurse practicing within a transition perspective should conduct assessment at different critical points to track progress through the transition, and to identify situations in which there are deviations from the norm (Meleis, 2010).

Role Supplementation Defined as the process of bringing into awareness the behaviors, sentiments, sensations, and goals involved in a given role (Meleis, 1975), this nursing therapeutic involves facilitating new knowledge through role-modeling, support, and revision of skills and capabilities (Schumacher et al., 1999).

Creation of a Healthy Environment In this instance, environment is broadly defined as a person’s physical, social, political, and cultural surroundings (Schumacher et al., 1999). The nurse’s role is to work with the patient and family to create a healthy environment to meet their needs and to promote dignity and personal integrity.

Mobilization of Resources For persons in transition, this is an important aspect of nursing practice because previously developed resources may no longer be adequate. These resources include personal, family, and community assets. Nurses can also mobilize older adults’ personal resources, such as immunity and energy, through health promotion and advice about exercise, diet, and a healthy lifestyle (­Schumacher et al., 1999). The concept of nursing therapeutics, therefore, extends across all stages of transition. Meleis’s theory of transition uses a framework that closely relates to and conceptualizes the metaparadigm concepts of nursing but also focuses on nursing practice.

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING Published nursing research since the 1990s that applied Meleis’s Transitions Theory as a guiding structure has served to extend and refine the framework. In order to conceptualize and theorize, transitions research was conducted with diverse populations: first-time African American mothers (Sawyer, 1999); Korean women experiencing menopause (Im & Meleis, 1999); parents of children with a diagnosis of congenital heart disease (CHD) (Messias, Gilliss, Sparacino, Tong, & Foote, 1995); Brazilian women who had migrated to the United States (Messias, 1997); and family caregivers of patients receiving chemotherapy (Schumacher & Meleis, 1994). Later,

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Transitions Theory was tested in a number of empirical studies; for example, the development of the family caregiving role for patients in chemotherapy (Schumacher, 1995); Korean immigrant women’s menopausal transition (Im & Meleis, 1999); the aging transition (Schumacher et al., 1999); relatives’ experience of nursing home care (Davies, 2005); perceived readiness for discharge in adult medical and surgical patients (Weiss et al., 2007); and transition experiences of stroke survivors following discharge home (Rittman, Boylstein, Hinojosa, Sberna Hinojosa, & Haun, 2007). The majority of researchers using Meleis’s theory have employed qualitative research methods. Sawyer (1999), for example, used grounded theory. Semistructured interviews with thematic analysis were used by Im and Meleis (1999) and Davies (2005); narrative analysis was used by Messias (1997); phenomenology by Messias et al. (1995); and Rittman et al. (2007) obtained qualitative data from indepth interviews and field observation. Recently, a number of research studies conducted in the United States and underpinned by Meleis’s transitional theory have used quantitative methods (specifically survey questionnaires) to examine readiness for discharge with mothers of hospitalized children (Weiss & Piacentine, 2006), adult medical and surgical patients (Weiss et al., 2007), and postpartum mothers (Weiss, Ryan, & ­Lokken, 2006). Meleis’s theory has been described as useful in identifying factors that facilitate or inhibit a successful transition (Davies, 2005). Analysis of data from a number of studies has revealed outcomes consistent with the Transitions Theory propositions. Sawyer (1999), to illustrate, identified two conditions that affected the transition experience for new mothers: birth experience and response. Parents of children diagnosed with CHD described their experience as creating new “meanings” in their own and their children’s lives (Messias et al., 1995). The lived experience of migration was characterized, according to Messias (1997), by different life phases, conditions, statuses, and self-redefinition. Results of these studies suggested that the pattern of a transition was important, and supported the notion that a number of patterns of transition could occur and be experienced at the same time. Weiss et al. found Meleis’s Transitions Theory to be a useful model for conceptualizing and investigating the readiness for discharge of adult medical and surgical patients. Relationships identified in the theory were consistent with the findings of the study; that is, the nature of the transition (type of admission, length of stay) and the nursing therapeutics (discharge teaching) had an impact on the pattern of response (Weiss et al., 2007). Davies, in her study of relatives’ experiences of nursing home entry, also found evidence to support the use of Meleis’s framework; however, she suggested that there were important omissions in the theory when adapted to the context in which her study was set. For instance, she suggested that further application of Meleis’s theory should consider the “reciprocal relationships” among service users, service providers, and family within different care settings (Davis, 2005, p. 670). In a concept analysis of health/illness transitions and telehealth (an integrated system of postdischarge support), Marineau (2006) also supported the work of Meleis and colleagues. According to Marineau, through the use of Meleis’s theory, factors were identified that would play a role in identifying patients and families who are eligible for discharge using telehealth. Overall, the use of Meleis’s middle range theory has been accepted by researchers as a useful framework for conceptualizing a wide range of transitions, including transitions in health and illness. Meleis’s middle range theory was thus deemed a suitable framework to guide this present research, and it was envisaged that the present study would serve to further the development of the theory concepts used.



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USE OF THE THEORY IN THIS RESEARCH The primary aim of this research is to examine the readiness of older people at discharge from acute hospital care to home, using demographic characteristics, hospitalization factors, physical and cognitive function, patients’ perceptions of their readiness, and available community supports and services. A secondary aim is to examine relationships between readiness at discharge and postdischarge interaction with community supports and services, including readmission. Going home from the hospital has commonly been referred to as a transition for the patient and the family (Weiss et al., 2007) that begins prior to discharge and extends into the postdischarge period (Meleis et al., 2000). Given that the focus of this study is on the transition from hospital to home, a theoretical definition of transition in the context of health is seen as most appropriate. Meleis et al. described transition in the context of health as a change in health status, role relations, expectations, or abilities. Transition may require the person to acquire new knowledge, to alter behavior, and hence to change the definition of self in social context, healthy- or ill-self, or internal or external needs (Meleis et al., 2000). Meleis et al. interpreted transition using a conceptualization of transition that reveals a holistic understanding of the conditions that influence the transition experience for patients (Schumacher & Meleis, 1994). As the experience of discharge is influenced by the conditions in which this transition occurs, one must be considerate of nursing measures that are appropriate to transitional care (Meleis et al., 2000). A neotheoretical construction (Figure 4.1) was developed from Meleis’s theory of transition to guide the study. This framework consists of three of the major concepts: nature of the transition, transition conditions, and pattern of response. The nature of the transition denotes the type, pattern, and properties of the transition. According to Meleis et al., transitions can be marked by critical events such as change in abilities, completion of a treatment, or relocation. In the current study, the type of transition is discharge from the hospital, and the pattern and properties of the transition are operationalized through the dimensions of patient demographic factors (age, gender, marital status, living arrangement) and hospitalization factors (admission type, length of stay, primary diagnosis, and comorbidity). The concept transition conditions, as described by Meleis et al., include personal and environmental conditions that may facilitate or hinder progress toward a healthy transition. Following a review of research literature on discharge, the personal conditions of influence for the purpose of this study are cognitive function, physical function (in activities of daily living [ADL]), and patients’ perceptions of readiness for discharge. Environmental conditions of influence, according to Meleis et al. (2000), are community resources and societal conditions. Dimensions chosen to represent these factors in the neotheoretical framework are community supports and services. The third theory concept included in this neotheoretical framework is pattern of response. The pattern of response to a transition, detailed by Meleis et al. (2000), can be indicated by process and outcome indicators. Process indicators are feeling connected, interacting, location and being situated, and developing confidence and coping; outcome indicators are described as mastery and fluid integrative identities. A review of literature revealed that little was known about older patients’ connection and interaction with supports and services postdischarge. Therefore, the process indicators of

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Part II  Theories Applied to Research Figure 4.1  Neotheoretical framework of Meleis’s Transitions Theory. Sample of people older than age 65 being discharged from acute care hospitals and at home 6 weeks later. At Discharge Postdischarge

Concept

Nature of transition

Pattern of response

Transition conditions

Type: Health/Illness

Personal

Environmental

Process indicators:

Discharge from hospital to home

Dimensions

Pattern and properties: Primary diagnosis

Meaning

Cognitive and physical function

Type of admission Length of stay Comorbidity

Preparation and knowledge

Community resources/ societal conditions

Patients’ perception of readiness

Planned and available community supports/ services (formal and informal)

Readiness for Hospital Discharge Scale (Weiss & Piacentine, 2006)

Researcherdeveloped community resources questionnaire

Age, gender, living arrangements Measure

Demographic questionnaire Charlson Comorbidity Index (1987) Comorbidity

Mini-Mental State Examination Barthel Index

Location and being situated Feeling connected and interacting Postdischarge community supports and services (formal and informal) Researcherdeveloped community resources questionnaire

Adapted from Meleis et al. (2000).

location/being situated and feeling connected/interacting were deemed appropriate to include in the neotheoretical framework. These indicators are demonstrated by the older persons’ living location and their use of supports and services postdischarge, including readmission to the hospital.

Operational Definitions The operational definitions of the concepts of nature of the transition, transition conditions, and pattern of response as outlined in the neotheoretical framework are delineated in the following paragraphs. Nature of the Transition: Type, Pattern, and Properties The type of transition in this study is identified as discharge from the hospital to home. The pattern and properties of the transition are identified by the patients’ demographic characteristics (age, gender, marital status, and living



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arrangement); hospitalization factors (type of admission, whether emergency admission or planned admission); and patients’ primary medical diagnosis, comorbidity, and the length of stay in the hospital. Demographic and hospitalization variables are recorded, and comorbidity is determined using the Charlson Comorbidity Index (Charlson, ­Pompei, Ales, & McKenzie, 1987). The inclusion of these variables is linked to the propositions of the Transitions Theory, which proffered that the pattern and properties of a transition may influence the pattern of response. Thus, older patients’ hospitalization factors may influence their postdischarge response. Transition Conditions: Personal The dimensions of personal transition conditions are meaning, preparation, and knowledge. Meaning is the understanding and recognition of the experience of discharge and can be influenced by patients’ characteristics and their cognitive function. Meaning of the discharge transition can also be influenced by patients’ expectations of their competence in self-care. Hence, meaning is also operationalized as physical function in self-caring activities such as ADLs. Knowledge and preparation for discharge are operationalized through the patients’ perceptions of their readiness for discharge. The dimensions are described in the following sections. Physical function, identified as the older persons’ ability to perform basic selfcaring activities, is measured using the Barthel Index of ADLs—grooming, feeding, bathing, stairs, dressing, mobility, transfer from bed to chair and back, toilet use, bowels, bladder (Mahoney & Barthel, 1965). Cognitive function, defined as the processes by which an individual perceives, registers, stores, retrieves, and uses information (Foreman et al., 1996), is identified in this study by the older persons’ ability in orientation, registration, attention, calculation, recall and language. The MMSE (Mini-Mental State Examination) scale (­Folstein, Folstein, & McHugh, 1975) is used to measure attention, recall, naming two items shown, repetition of a phrase, following verbal and written commands, writing a sentence, and copying a diagram (Folstein et al., 1975). Readiness for discharge identifies the older patients’ perceptions of their personal status, their knowledge about caring for their personal needs, their coping abilities, and their expected support postdischarge. Personal status is the patient’s physical and emotional state at the time of discharge. Knowledge is the perceived adequacy of the information needed to respond to common concerns and problems postdischarge. Coping ability refers to the patient’s perceived ability to self-manage personal and health care needs postdischarge. Expected support refers to the emotional and instrumental assistance expected by the patient to be available following hospital discharge. Readiness for discharge is measured using the Readiness for ­Hospital Discharge Scale (Weiss & Piacentine, 2006). Transition Conditions: Community and Societal Community resources and societal conditions, two dimensions of environmental transition conditions, are defined in this study as the planned and available ­community supports and services (informal and formal) at discharge.

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With regard to formal supports and services, questions are based on a review of current community supports and services available for older people within Irish health and social services. These include home help, Meals on Wheels, community transport, outpatient physiotherapy, visits from/to public health nurses, visits to/ from general practitioner, outpatient occupational therapy, chiropody/podiatry, social worker services, day care, and respite care. Pattern of Response Process indicator—Location and being situated. This dimension is identified by the respondent’s living arrangement postdischarge, which pertains to change in living arrangement or location since discharge. If the response is yes to a change in living arrangement, the respondent’s location at the time of data collection is recorded if known. Process indicator—Feeling connected and interacting. This theory dimension is operationalized as the use of informal support (family) and formal supports and services (general practitioner, public health nursing, home help, and other available community services) postdischarge. Pattern of response is also characterized as readmission to the hospital.

THEORY ANALYSIS To evaluate the use of the Transitions Theory for this research, Fawcett’s (2005) theory evaluation criteria are used (Table 4.1). Using the results of this study to examine the readiness of older people at discharge and their use of supports and services in the postdischarge period supports the use of Meleis’s middle range theory of transition as an appropriate theoretical framework to underpin research into the discharge transition for older people. The results provide evidence, similar to that of Davies (2005), that the theory is useful in identifying factors associated with the discharge transition. Also similar to Weiss et al. (2006), outcomes provide evidence of relationships consistent with the theory propositions. As discussed previously, Meleis proposes in her theory that the “nature of the transition” can facilitate or hinder a person’s “pattern of response” (Meleis, 2010). This proposition is supported by results that demonstrate that patterns and properties of the discharge transition— such as hospital admission type, length of stay, diagnosis, and comorbidity, along with demographic characteristics—of older patients are statistically associated with their interaction with supports and services postdischarge. Findings also support the theory proposition that both personal and environmental “transition conditions” influence the pattern of response for older people postdischarge. However, application of the theory should extend the “personal” dimension of the concept transition conditions to include physical and cognitive indicators because findings are that significant statistical relationships exist between older patients’ physical and cognitive function at discharge and their response (i.e., interaction with supports and services) postdischarge. Relationships identified in Meleis’s theory with regard to preparation and knowledge and pattern of response are also supported by the findings of this research. Significant statistical relationships are found between older patients’ perceptions of their readiness for discharge and their use of both informal and formal supports in the



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Table 4.1 Evaluative Criteria and Use of Meleis’s Transitions Theory in the Study Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

Yes, the theory focuses on the relationships among the concepts: nature of the transition, transition conditions, and pattern of response. Therefore, it fits with this study in that discharge from the hospital may be influenced negatively or positively by the older persons’ personal and environmental conditions at discharge and their use of support postdischarge—pattern of response.

2.

Is it readily operationalized?

Yes, each concept and specific dimension described can be directly linked to the discharge transition. The type of transition is health/illness, and the pattern and properties are operationalized as demographic and hospitalization factors. Transition conditions are operationalized as the older persons’ physical and cognitive conditions on discharge and their readiness for discharge. Pattern of response is operationalized using their interaction with community support, readmission, and living situation.

3.

How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it is related?

The theory has previously been used to describe developmental transitions through the life cycle. For example, becoming a mother (Mercer, 2004); situational and health/illness transitions—immigrant women’s menopausal transitions (Im & Meleis, 1999); readiness for hospital discharge (Weiss et al., 2007); experience of stroke victims following discharge (Rittman et al., 2007); relatives’ experience of nursing home entry (Davies, 2005). In all studies, the theory is useful in articulating the phenomena being explored. Similar to the current study, Weiss et al. (2007) used Transitions Theory as a guiding framework for a study of readiness of adult medical/surgical patients for discharge. Transition ­conditions measured were readiness for discharge, discharge teaching, and care coordination. The pattern of response was measured using a postdischarge coping ability and utilization of support and services. Outcomes and predictors of readiness for discharge were identified. The theory was useful both in Weiss et al. (2007) and in the current study to identify study variables because of the congruence between the concepts and dimensions of the theory and the discharge transition.

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

Hypothesis # 1: There are relationships among respondents’ demographic characteristics and hospitalization factors at discharge: functioning (physical and cognitive), perception of their readiness for discharge at discharge, and informal support (with ADL, household activities, medication, and transport) received at 6 weeks postdischarge from acute care hospitals. Hypothesis # 2: There are relationships among the characteristics of older people and their functioning (physical and cognitive) at discharge: perception of readiness at discharge, use of formal supports and services (home help, public health nursing, additional community services) at 6 weeks postdischarge from acute care hospitals. Hypothesis # 3: There are relationships among respondents’ demographic characteristics, hospitalization factors, and physical/cognitive functioning, along with readiness at discharge and readmission, within 6 weeks postdischarge from acute care hospitals. (continued)

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Table 4.1 Evaluative Criteria and Use of Meleis’s Transitions Theory in the Study (continued) Questions for evaluation

Responses to questions

Hypothesis # 4: There is a relationship between supports and services (informal and formal) at discharge and postdischarge and readmission within 6 weeks postdischarge. The theory relates to and addresses the research hypotheses in its description and explanation of the relationships among nature of the transition (discharge, demographic, and hospitalization factors), transition conditions (physical and cognitive function, and perception of readiness), and pattern of response (interaction with supports and services following discharge). Therefore, it fits with the research hypotheses of this study. 5.

Does the theory flow from the research question?

The theory guided the development of the research question and hypotheses that relationships exist among the nature of the discharge transition, the personal and environmental conditions of the patients at discharge, and their use of community support and readmission.

6.

Does the theory address the ­primary and ­secondary research questions?

The theory addresses the primary and secondary research questions. It describes the patients’ pattern of transition: hospitalization factors, transition conditions (physical, cognitive, and readiness), and patients’ response (use of community services postdischarge). The theory also supports the testing of relationships among these concepts and dimensions.

7.

Are the assumptions congruent with the assumptions that are made for research?

The assumptions are congruent with the assumptions that are made for the research in that: (a) there are directional relationships among type of discharge, personal and environmental conditions at discharge— including readiness and use of community supports postdischarge; (b) transition conditions can be personal and environmental; and (c) health care professionals should include the older persons’ perspectives in the discharge process.

8.

Is the theory oriented to outcomes that are critical to patients?

The theory is oriented to outcomes that are critical to patients. It identifies that condition of older patients at discharge is related to their subsequent use of community supports and readmission. It allows for patients’ individual perceptions of their readiness for discharge to be ascertained, and indicates the importance of nursing interventions in a person-­ centered discharge process.

9.

Are tools available to test relationships of the theory or do they need to be developed?

In the current study, the nature of the discharge transition is measured using a questionnaire to record demographic and hospitalization factors. The Charlson Comorbidity Index (Charlson et al., 1987), the Barthel Index (Mahoney & Barthel, 1965), and the Mini-Mental State Examination (­Folstein, Folstein, & McHugh, 1975) are used to measure the personal transition conditions, along with the Readiness for Hospital Discharge Scale (Weiss et al., 2007). A researcher-developed community resource questionnaire is used to record pattern of support use and readmission postdischarge. It is possible to test relationships among variables in using these scales. The community resource questionnaire needs to be developed and tested further.

Source: Bredow (2004), Fawcett (1999).



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postdischarge period. The inclusion of patients’ perceptions of their readiness with regard to preparation and knowledge is therefore indicated as a further development of the theory. This research also provides evidence to support the theory concept of nursing therapeutics. Relationships found between patients’ own perceptions of their readiness at discharge and their subsequent interaction with community supports suggest that knowing and valuing the older person’s perspective and knowledge are also essential for clinical judgment and effective therapeutic caring (Dewing, 2004; McCormack, 2004). Nurses need to consider that priorities of older people can differ from those of care providers (Themessl-Huber, Hubbard, & Munroe, 2007). The therapeutic role of nursing in assessment is strongly supported by the relationships in this research between older patients’ physical and cognitive functioning at discharge and their use of supports and services postdischarge. The nurse’s role in the identification and tracking of older patients’ progress from a transition perspective is emphasized. This is to enable the identification of any deviation from the norm (Meleis, 2010) and to identify the need for resources. Nursing therapeutics involved in the mobilization of resources, according to Meleis (2010), have particular relevance for older people. The results of this present research in the context of the discharge transition support the theory proposition that community resources include both informal and formal supports and services. Gaps can occur in the continuity of care and support for older patients with potentially poor outcomes (Hadjistavropoulous, Biem, Sharpe, Bourgault-Fagnou, & Janzen, 2008). Findings of increased informal supports postdischarge in this study suggest that family resources may need to be supplemented to assist recovery and ongoing care (Meleis, 2010). Low perception of readiness with regard to knowledge and high dependence on support postdischarge emphasize the role of nursing therapeutics in the facilitation of new knowledge through discharge teaching and the mobilization of the older adults’ personal resources through health promotion and advice (Schumacher et al., 1999).

RECOMMENDATIONS FOR FURTHER RESEARCH Because perceptions of readiness may differ among patient, family, and health professionals, further research (e.g., using the Readiness for Hospital Discharge Scale) can be undertaken to examine the patient’s nurse and family perceptions of readiness for discharge. This indicates whether diversity exists between the reality for the patient at discharge and perspectives of others, and promotes the inclusion of older patients’ perspectives in needs assessment. Older people’s expectations, preferences, perceptions of need, experiences, and satisfaction with home care services and supports in the community should be explored through further study. To encourage a person-centered approach, it is necessary to examine differences or similarities between older patients’ assessed need for services by health care practitioners and their perceived need for these services. The experiences of older family members in providing support—particularly during the discharge transition—should be explored to highlight their particular challenges and issues, and to inform practice with regard to the augmentation of older caregivers’ roles. To gain a more in-depth understanding of the basis for this

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result, further investigation is necessary with care receivers and caregivers to explore ­cultural, educational, and socioeconomic influences on family care and support for older people.

SUMMARY This chapter discusses Meleis’s middle range Transitions Theory and its use as a framework for an empirical study of older people’s readiness for discharge from the hospital to home. Going home from the hospital has been commonly referred to as a transition for patient and family that begins prior to discharge and extends into the postdischarge period (Meleis et al., 2000). Since the early 1980s, Meleis and colleagues in the United States have been developing a theory of transitions that conceptualized transitions using four main concepts: nature of transition, transition conditions, pattern of response, and nursing therapeutics. Although there are several types of transition, those that are linked to health or illness more often bring people into contact with nursing care (Schumacher et al., 1999). Transitions Theory is easy to understand. The relationships among the main concepts are clear. Transitions Theory has been shown through empirical research to explain the complex relationships and provide a number of assumptions that can be made from theoretical understanding of different transition types. The theory continues in its development through research programs with diverse groups. Further exploration is necessary to test the theory and refine the concepts and dimensions within different environments, situations, and with contrasting populations.

References Bredow, T. S. (2004). Analysis, evaluation and selection of a middle range nursing theory. In S. J. Peterson & T. S. Bredow (Eds.), Middle range theories: Application to nursing research (pp. 42–56). Philadelphia, PA: Lippincott Williams & Wilkins. Charlson, M. E., Pompei, P., Ales, K. L., & McKenzie, C. R. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Disease, 40, 373–383. Chick, N., & Meleis, A. I. (1986). Transitions: A nursing concern. In P. L. Chinn (Ed.), Nursing research methodology: Issues and implementation (pp. 237–257). Rockville, MD: Aspen. Davies, S. (2005). Meleis’s theory of nursing transitions and relatives’ experiences of nursing home entry. Journal of Advanced Nursing, 52(6), 658–671. Dewing, J. (2004). Concerns relating to the application of frameworks to promote person-­ centeredness in nursing with older people. Journal of Clinical Nursing, 13(s1), 39–44. Fawcett, J. (1984). The metaparadigm of nursing: Present status and future refinements. Journal of Nursing Scholarship. doi:10.1111/j.1547-5069.1984.tb01394.x Fawcett, J. (1999). The relationship of theory and research. Philadelphia, PA: F.A. Davis. Folstein, M., Folstein, S., & McHugh, P. (1975). “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. Foreman, M. D., Fletcher, K., Mion, L. C., Lark, S., & Niche Faculty. (1996). Assessing cognitive function. Geriatric Nurse, 17(5), 228.



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Hadjistavropoulos, H., Biem, H., Sharpe, D., Bourgault-Fagnou, M., & Janzen, J. (2008). Patient perceptions of hospital discharge: Reliability and validity of a patient continuity of care questionnaire. International Journal for Quality in Health Care, 20(5), 314–323. Im, E.-O. (2009). Transitions Theory. In A. M. Twoomey & M. Alligood (Eds.), Nursing theorists and their work (7th ed., pp. 416–433). St. Louis, MO: Mosby/Elsevier. Im, E.-O., & Meleis, A. I. (1999). A situation specific theory of menopausal transition of Korean immigrant women. Image Journal of Nursing Scholarship, 31, 333–338. International Council of Nurses (ICN). (2010). Definition of nursing. Retrieved from http:// www.icn.ch/about-icn/icn-definition-of-nursing Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. State Medical Journal, 14, 61–65. McCormack, B. (2004). Person-centeredness in gerontological nursing: An overview of the literature. International Journal of Older People Nursing (in association with the Journal of Clinical Nursing), 13, 31–38. Meleis, A. I. (1975). Role insufficiency and role supplementation: A conceptual framework. Nursing Research, 24(4), 264–271. Meleis, A. I. (1991). Theoretical nursing: Development and progress (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Meleis, A. I. (2010). Transitions Theory: Middle range and situation specific theories in research and practice. New York, NY: Springer Publishing Company. Meleis, A. I., Sawyer, L. M., Im, E.-O., Messias, D. K., & Schumacher, K. (2000). Experiencing transitions: An emerging middle-range theory. Advances in Nursing Science, 23(1), 12–28. Meleis, A. I., & Trangenstein, P. A. (1994). Facilitating transitions: Re-definition of the nursing mission. Nursing Outlook, 42, 252–259. Mercer, R. T. (2004). Becoming a mother versus maternal role attachment. Nursing Scholarship, 36(3), 226–232. Messias, D. K. H. (1997). Narratives of transnational migration work and health: The lived experiences of Brazilian women in the United States (Doctoral dissertation). Retrieved from ProQuest ­Dissertations and Theses database. (UMI No. 9806893) Messias, D. K. H., Gilliss, C. L., Sparacino, P. S. A., Tong, E. M., & Foote, D. (1995). Stories of transition: Parents recall diagnosis of congenital heart defects. Family Systems Medicine, 3(3/4), 367–377. Rittman, M., Boylstein, C., Hinojosa, R., Sberna Hinojosa, M., & Haun, J. (2007). Transition experiences of stroke survivors following discharge home. Topics in Stroke Rehabilitation, 14(2), 21–31. Sawyer, L. M. (1999). Engaged mothering: The transition to motherhood for a group of African American women. Journal of Transcultural Nursing, 10(1), 14–21. Schumacher, K. L. (1995). Family caregiver role acquisition: Role-making through situated interaction. Research and Theory for Nursing Practice, 9(3), 211–226. Schumacher, K. L., Jones, P. S., & Meleis, A. I. (1999). Helping elderly persons in transition: A framework for research and practice. In E. A. Swanson & T. Tripp-Reimer (Eds.), Life transitions in the older adult: Issues for nurses and other health professionals (pp. 1–26). New York, NY: Springer Publishing Company. Schumacher, K. L., & Meleis, A. I. (1994). Transitions: A central concept in nursing. Journal of Nursing Scholarship, 26(2), 119–127. Schumacher, K. L., & Meleis, A. I. (2010). Transitions: A central concept in nursing. In A. I. Meleis, Transitions Theory: Middle range and situation specific theories in research and practice. New York, NY: Springer Publishing Company.

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Part II  Theories Applied to Research Themessl-Huber, M., Hubbard, G., & Munroe, P. (2007). Frail older people’s experiences and uses of health and social care services. Journal of Nursing Management, 15(2), 222–229. Weiss, M. E., & Piacentine, L. B. (2006). Psychometric properties of the Readiness for Hospital Discharge Scale. Journal of Nursing Measurement, 14(3), 163–180. Weiss, M. E., Piacentine, L. B., Lokken, L., Ancona, J., Archer, J., Gressler, S., . . . Vega-Stromberg, T. (2007). Perceived readiness for hospital discharge in adult medical-surgical patients. Clinical Nurse Specialist, 21(1), 31–42. Weiss, M., Ryan, P., & Lokken, L. (2006). Validity and reliability of the readiness for discharge after birth scale. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(1), 34–45. Wilkins, K. L., & Woodgate, R. L. (2006). Transition: A conceptual analysis in the context of siblings of children with cancer. Journal of Paediatric Nursing, 21(4), 256–265.

chapter 5

Theory of Planned Behavior Nicola Cornally

The Theory of Planned Behavior was developed by psychologist Professor Icek ­Fishbein (Ajzen, 1985). It stemmed from the Theory of Reasoned Action that was developed to explore the relationship between attitudes and action (Fishbein & Ajzen, 1975). This variable of perceived behavioral control is unique to the Theory of Planned Behavior. This supplementary component particularly pertains to behavior that may not be completely controlled by the individual (Ross, Connie, Kohler, ­Grimley, & Anderson-Lewis, 2007). The theory has been applied to health-related behaviors, and its popularity is evidenced by its citation in thousands of peerreviewed publications. This chapter presents an overview of the Theory of Planned Behavior, its historical development, and its use in other disciplines. Following this, a description of how it links to nursing metaparadigms is discussed. The Theory of Planned Behavior is evaluated using Fawcett’s (1999) criteria adapted from Bredow (2004); this exercise demonstrates the strengths and inherent weaknesses of the model. Two nursing research examples are provided to demonstrate the application of the Theory of Planned Behavior. These studies investigate help-seeking behavior (HSB) for chronic pain and influenza vaccination uptake behavior. Finally, areas for further research using the theory are outlined.

BASIC DESCRIPTION OF THE THEORY The Theory of Planned Behavior assists researchers who endeavor to predict and explain a variety of behaviors. The theory has four main constructs: attitudes, subjective norms, perceived behavioral control, and behavioral intention. The theory postulates that the decision to enact a behavior is primarily influenced by persons’ attitudes, the pressure they perceive from others (subjective norm), and their discernment of how difficult it would be to perform the behavior (perceived behavioral control). These constructs serve as predictor variables and are said to be fashioned from a person’s beliefs about the behavior (behavioral beliefs), the beliefs of others (normative beliefs), and beliefs about ability and control regarding the behavior (control

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beliefs). Termed explanatory variables, it is these variables that enable the researcher to explain why people behave in a certain way. In essence, the Theory of Planned Behavior is a suitable framework for identifying and understanding modifiable variables that predict and explain a variety of different behaviors, from safe-sex practices (Bryan, Fisher, & Fisher, 2002) to blood donation (Giles, 1995). Historically, the relationship between attitudes and behavior has been described as contentious. Indeed, a famous review of the literature by Wicker in 1969 cast doubt over the existence of any significant relationship between the two constructs. Despite the commonly held view that attitudes toward a particular behavior directed action, there was a dearth of empirical evidence to support this contention. Fishbein and Ajzen (1975) have written extensively on this issue, acknowledging the disparity among researchers regarding the attitude–behavior relationship. Against this background they developed the Theory of Reasoned Action and placed behavioral intention central to the model to act as a mediator among attitudes, subjective norms, perceived behavior control, and actual behavior (Armitage & Christian, 2003). In addition, Ajzen (1991) presented three distinct arguments to account for the poor correlations found between attitudes and behavior in the review by Wicker (1969). The first of these is in relation to the validity of the measurements of attitudes. He suggests that many responses may have reflected socially d ­ esirable answers rather than actual attitudes. A second reason was to account for the fact that attitudes were reported as poor predictors of behavior—failure to measure attitudes toward the defined behavior. He contends that one cannot measure ­general attitudes when investigating a specific behavior. Furthermore, he argues, that behavior should be defined using the TACT (Table 5.1) principle (i.e., the target, action, context, and time of the behavior). This must be clearly delineated, and serves to strengthen the correlations between the independent and dependent variables. Third, he states that attitudes are more likely to be accurate predictors of behavior when behaviors are self-involving (Table 5.2). As shown in Table 5.2, people think differently and may even formulate different beliefs and attitudes about how others should behave, as opposed to behaviors in which they are directly involved. When individuals place themselves at the heart of the behavior, a multitude of influencing variables resonate that may be absent when thinking of the behavior in general. It is important to note that self-involving behaviors are more likely to evoke a more valid response from a study participant and thus reduce the gap between attitudes and actual behavior.

Table 5.1 TACT Principle Example of TACT principle applied to the behavior of “seeking help from a health care professional for chronic pain in the next 6 months” Target – Health care professional Action – Seeking help Context – Chronic pain Time – 6 months



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Table 5.2 Self-Involving Behavior Generalized statement

Self-involving

Nurses should assess patient’s vital signs.

I, as a nurse, should assess my patient’s vital signs.

Smoking is unhealthy; people should not smoke.

Smoking will harm me; I should give up smoking.

It is important that people get vaccinated against influenza.

I will get vaccinated against influenza this autumn.

CORE CONCEPTS The theory postulates that behavioral intention is determined by three key constructs: attitudes, subjective norms, and perceived behavioral control. Each construct is composed of salient beliefs; these are described as behavioral beliefs, normative beliefs, and control beliefs (Ajzen, 1991). Each belief is linked to a certain outcome; only if the outcome is valued by the person does it affect intention (Armitage & Christian, 2003). These assumptions are largely based on the Expectancy Value Model, the foundation of the Theory of Planned Behavior (Ajzen, 1991). Ajzen writes that attitudes, subjective norms, and perceived behavioral control are “three conceptually independent determinants of intention” (p. 188) that form the Theory of Planned Behavior. Each of the three constructs is discussed sequentially, with the central component, behavioral intentions, presented first.

Intention Behavioral intention as a construct has received a great deal of attention in the psychology literature for decades; however, the integration of the construct into models of health and illness behavior has increased its popularity among nurse researchers. According to Armitage and Christian (2003), the strength of people’s intentions demonstrates their willingness to enact a behavior. In addition, “behavioral intentions are assumed to capture the motivational factors that influence behavior” (Ajzen, 1991, p. 181).

Attitude An attitude is defined as “a learned disposition to respond to an object in a consistently favorable or unfavorable manner” (Fishbein & Ajzen, 1975, p. 336). Attitudes are fashioned from beliefs regarding the consequences of the behavior and the personal evaluation of these outcomes. For example, a favorable attitude toward seeking help for chronic pain could be constructed from the following beliefs: Seeking help will more than likely reduce pain (expected outcome); reducing pain is desirable (outcome evaluation). When expected outcome is summed with outcome evaluation, the result is that the behavioral belief and attitudes are directly determined by these beliefs. It is assumed that a positive attitude is formed based on the above beliefs; thus, individuals are more likely to seek help for their chronic pain. Conversely, a formed negative attitude has the opposite effect. For example, a person may believe: If I seek help the doctor will give me medication (expected outcome); taking medication is not

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good for me (outcome evaluation). Expected outcome times outcome evaluation equals behavioral belief. The behavioral belief in this case produces a negative attitude toward the behavior of seeking help; thus, HSB is less likely.

Subjective Norm Other beliefs that are fundamental to behavioral intention are normative beliefs. Fishbein and Ajzen (1975, p. 16) postulate that “normative beliefs and motivation to comply lead to normative pressures and the totality of these pressures is termed, Subjective Norms.” As with attitudes, subjective norms are determined by salient beliefs; however, they are termed normative beliefs. These are again calculated based on the Expectancy Value Model. Yet, it is salient beliefs of others that are considered, and the motivation to comply with these beliefs. For example, an individual may know that his wife thinks it is good for him to seek help; however, he may not be motivated to comply with the wishes of his wife. In this case, subjective norms would have little impact on intention to seek help. Or, put another way, if people feel that their families think it is not important to get help for chronic pain and they are motivated to comply with these beliefs, then this may negatively impact on behavioral intention and subsequent behavior. In others words, people may feel pressured to conduct certain behaviors due to external stimuli, such as the beliefs of others or of society.

Perceived Behavioral Control The component of perceived behavioral control distinguishes the Theory of Planned Behavior from the Theory of Reasoned Action. This supplementary component particularly pertains when the behavior may not be completely controlled by the individual (Ross et al., 2007), and helps to explain more complex behaviors—such as seeking help when many factors may inhibit or facilitate the occurrence of the behavior. Perceived behavioral control “is expected to reflect past experiences as well as anticipated impediments and obstacles” (Ajzen, 1991, p. 188). Ogden (1996) cites this as one of the strengths of the Theory of Planned Behavior and places this model above others, such as the Health Belief Model. However, Ajzen (2002) states that perceived behavioral control is similar to the barriers described in the Health Belief Model (Rosenstock, 1966), and the facilitating conditions posited by the Model of Interpersonal Behavior (Triandis, 1980). In addition, he draws comparisons between perceived behavioral control and the concept of self-efficacy fashioned by Bandura (1977), noting that both refer to the “person’s ability to successfully execute a ­behavior” (p. 667). According to Nash, Edwards, and Nebauer (1993), perceived behavioral control is where people believe that they have the means and opportunities to carry out a particular behavior; these can be subdivided into internal and external control factors. Internal control factors are said to include aspects of knowledge and ability, whereas external control factors relate to tangible obstacles or opportunities (­Conner & Armitage, 1998). These factors make executing the behavior easier or more difficult. In the case of help-seeking, external factors may include availability of a source of help and the approachability of the helper. Conversely, the internal factors are said to relate directly to self-efficacy with carrying out the behavior (i.e., confidence that one could seek help, if wanted) and personal controllability over the behavior (i.e., seeking help is entirely up to the individual) (Conner & Armitage, 1998).



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According to Armitage and Christian (2003, p. 192), the component of “perceived behavioral control added significantly to the prediction of intention and behavior.” Despite this, however, there is some evidence to suggest that perceived behavioral control demonstrates the weakest relationship with behavioral intention (Mo & Mak, 2009; Schomerus, Matschinger, & Angermeyer, 2009). These researchers suggest a more detailed measure of the concept of perceived behavioral control to reflect that the concept of self-efficacy is required to improve the predictability of this component. A description of the main tenets of the theory is offered by Ajzen (2006, p. 1). He writes that “action is guided by three considerations: beliefs about the likely outcomes of the behavior and evaluations of these outcomes, beliefs about the normative expectation of others and motivation to comply, and beliefs about the presence of factors that facilitate or impede behavior and perceived power of these factors.” He goes on to explain that attitudes are fashioned from behavioral beliefs, subjective norms are produced from normative beliefs, and perceived behavioral control is determined by control beliefs. Together these concepts form behavioral intention. This depiction of the relationship between each variable is valuable for formulating hypotheses.

RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS THEORY The Theory of Planned Behavior has been used across a multitude of disciplines with varying degrees of success. Its use has been applied in basic correlational research, where an exploration of the determinants of a particular behavior is sought. To a lesser extent, the theory has been applied in complex intervention research (Table 5.3). Empirical literature from the past 10 years has demonstrated the utility of the Theory of Planned Behavior for investigating HSBs specifically. These include seeking help for signs of pneumonia in children by Peruvian mothers (Gálvez, Modeste, Lee, Betancourt, & Wilkins, 2002); cancer symptoms (Nooijer, Lechner, & Vries, 2003); breast cancer symptoms (Hunter, Grunfeld, & Ramirez, 2003); mental health problems among prison inmates (Skogstad, Deane, & Spicer, 2006); psychological

Table 5.3 Examples of Theory of Planned Behavior Studies From Other Disciplines Discipline

Study

Psychology (Giles & Rea, 1999)

“Career Self-Efficacy: An Application of the Theory of Planned Behavior”

Medicine (Mirkuzie, Sisay, Moland, & Åstrøm, 2011)

“Applying the Theory of Planned Behavior to Explain HIV ­Testing in Antenatal Settings in Addis Ababa—A Cohort Study”

Science and Technology (Shih & Fang, 2004)

“The Use of a Decomposed Theory of Planned Behavior to Study Internet Banking in Taiwan”

Education (Davis, Ajzen, Saunders, & Williams, 2002)

“The Decision of African American Students to Complete High School: An Application of the Theory of Planned Behavior”

Humanities and Social Science (Elliott, Armitage, & Baughan, 2007)

“Using the Theory of Planned Behavior to Predict Observed Driving Behavior”

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problems among older adults (Westerhof, Maessen, de Bruijn, & Smets, 2008); psychosocial support after cancer (Steginga et al., 2008); mental health problems in a Chinese population (Mo & Mak, 2009); depression in a general population (Schomerus et al., 2009); and depression among antenatal/postnatal women (Bennett et al., 2009).

RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS Fawcett (2005) describes human beings, environment, health, and nursing as defining concepts of the metaparadigm of nursing. The relationship of the Theory of Planned Behavior to each metaparadigm concept is discussed sequentially, beginning with human beings. The Theory of Planned Behavior seeks to understand human behavior. Why individuals do what they do underpins the very existence of the theory. Persons, their beliefs—which are culturally shaped—and the influence of family, friends, and society in general are all addressed within the theory. Although not developed with the specific purpose of explaining and predicting health behaviors, the Theory of Planned Behavior has been applied to various healthrelated contexts. Indeed, this is where it has gained the most recognition and success. Nurses strive to improve the health of those they come in contact with. They give patients exercises to do, initiate self-care strategies, offer discharge advice in the hope that it will be followed, and assign medication regimes. These health-related behaviors are adopted by some but not by others in their care. The evidence is unambiguous that increased engagement in these behaviors should lead to a better patient/ client outcome. However, it is a challenge for nurses, first, to understand what motivates patients/clients to behave in a certain way and, second, to introduce behavioral change. The Theory of Planned Behavior can assist nurses in this area and provides an empirically tested framework for intervention development. Of course, its utility extends beyond the delivery of health services and encompasses broader aspects of health to include disease prevention behavior (e.g., health promotion). Two factors can be considered in relation to the environment. First, the construct of subjective norms speaks to the influence of others; the theory purports that individuals are influenced by culturally accepted norms. Second, perceived behavioral control encompasses perceived barriers and facilitators to enacting behavior. These can relate to extrinsic environmental factors such as health care facilities, transport, geographical location, physical supports, and finance. The relationship of the theory to the metaparadigm concept of nursing is not so obvious. However, Fawcett (2005, p. 6) contends that this metaparadigm can “refer to actions taken by nurses.” Owing to the broad scope of the Theory of Planned Behavior, it can be—and has been—applied to enhance understanding of nursing assessment, planning, implementation, and evaluation of care action. For example, Edwards and colleagues (2001) investigated the factors influencing nurses’ behavior to use certain medication for pain management. More recently, in 2012 Côté, Gagnon, Houme, Abdeljelil, and Gagnon applied the theory to determine nurses’ intention to base clinical decision making on empirical evidence. Furthermore, as alluded to in the section on health, the theory provides a framework for nurses to develop care interventions.



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THEORY ANALYSIS This section addresses the broad analysis of the Theory of Planned Behavior, followed by an evaluation of the theory when applied to HSB for chronic pain. When analyzing a theory, Fawcett (2005) recommends examining the following three areas: scope, context, and content. Theory scope relates directly to its classification. The Theory of Planned Behavior can be described as a middle range theory based on the consensus that it is both predictive and explanatory (Ajzen, 1991). In addition, there is sufficient empirical guidance regarding the relationships between variables and assumptions; therefore, it could not be described as abstract. Theory context refers to both the metaparadigm concepts of nursing and the philosophical assumptions of the theory (Fawcett, 2005). It is evident from the previous section that the theory relates to all nursing metaparadigm concepts. Of the concepts discussed, environment emerged as maintaining the strongest association because the theory seeks to address primarily human patterns of behavior within a specific context. The philosophical claim upon which the theory is based is that people behave in a certain way when certain conditions are applied; these conditions relate to culture, environment, life experience, and relationship with self and others. A key question in theory analysis is “what world view is reflected in the theory?” (Fawcett, 2005, p. 442). Reciprocal interaction world view is reflected in the Theory of Planned Behavior (Villarruel, Bishop, Simpson, Jemmott, & Fawcett, 2001). This world view maintains the propositions that “human beings are holistic and active; interactions between humans and their environment are reciprocal; change is a function of antecedent factors; and reality is context dependent” (Fawcett, 2005, p. 13). Theory content relates to the examination of the theory concepts and assumptions. There is an abundance of literature reporting on the associations among the Theory of Planned Behavior concepts. Comprehensive guidance regarding the relation propositions of the theory is provided by the theorist, and this information has been made widely available and open for critique. According to Armitage and Christian (2003, p. 187) “several meta-analytic reviews provide strong empirical support for the Theory of Planned Behavior,” including the one they conducted that contained 185 studies (Armitage & Conner, 2001). The Theory of Planned Behavior is now evaluated within the context of its use in a recent study by the author on help-seeking for chronic pain (Cornally, 2012). This evaluation is based again on the work of Fawcett (1999, 2005) and adapted for ­Bredow (2004). Nine key questions are addressed (Table 5.4). In summary, the strengths of this theory relate to how well it performed at predicting and explaining HSB. For the study in question, up to 40% of variance was explained by the model. In addition, the description and explanation of the theory lend themselves to straightforward application. Sufficient empirical guidance regarding the relationships among variables is provided, allowing for theory-derived hypotheses to be generated. An issue that muddies the attractiveness of applying the theory relates to the need for instrument development. To combat this issue, comprehensive guidelines were published by the theorists (Ajzen, 2006; Fishbein & Ajzen, 2010) and experts in instrument development for Theory of Planned Behavior research (Francis et al., 2004).

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Table 5.4 Evaluative Criteria and the Theory of Planned Behavior When Applied to Seeking Help for Chronic Pain Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

The theory provides focus for the study of the facets involved in human decision making when a planned behavior is involved. This study sought to explore the factors influencing help-seeking behavior (HSB); thus, it is applicable to this research. HSB was previously defined in a concept analysis as a planned behavior (Cornally & McCarthy, 2011).

2.

Is it readily operationalized?

Yes, each construct (attitude, subjective norm, perceived behavioral control, and behavioral intention) can be measured both directly and indirectly. A multitude of studies exist (exceeding 1,000) in the literature where the theory has been operationalized for a variety of planned behaviors—some health-related.

3.

How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it relates?

Empirical literature from the past 10 years has demonstrated its utility for investigating and predicting help-seeking intentions in a variety of contexts, including seeking help for signs of pneumonia in children by Peruvian mothers (Gálvez, Modeste, Lee, Betancourt, & Wilkins, 2002); cancer symptoms (Nooijer, Lechner, & Vries, 2003); breast cancer symptoms (Hunter, Grunfeld, & Ramirez, 2003); mental health problems among prison inmates (Skogstad, Deane, & Spicer, 2006); psychological problems among older adults (Westerhof, Maessen, de Bruijn, & Smets, 2008); psychosocial support after cancer (Steginga et al., 2008); mental health problems in a Chinese population (Mo & Mak, 2009); depression in a general population (Schomerus, Matschinger, & Angermeyer, 2009); and depression among antenatal/ postnatal women (Bennett et al., 2009). It has performed well in terms of predictability, with most studies demonstrating up to 40% of variance.

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

A strength of the Theory of Planned Behavior is the sufficient empirical guidance regarding the relationships between variables and subsequent appropriate hypotheses’ formulation and testing (Vernberg, 1998). As a result, the hypotheses are theory derived and tested accordingly.

5.

Does the theory flow from the research question?

The research question asked: “What are the determinants of helpseeking for chronic pain?” By virtue of the fact that help-seeking is a planned behavior, the Theory of Planned Behavior was employed to guide and structure the entire study and allowed for a framework to be created for reviewing the literature. The theory was subsequently used to develop the conceptual framework upon which the methodology (hypothesis formulation) was based.

6.

Does the theory address the primary and secondary research questions?

The theory addresses the primary and secondary research questions: To investigate the determinants of HSB for chronic pain, and “Is the Theory of Planned Behavior a suitable framework for exploring HSB?” (continued)



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Table 5.4 Evaluative Criteria and the Theory of Planned Behavior When Applied to Seeking Help for Chronic Pain (continued) Questions for evaluation

Responses to questions

7.

Are the assumptions congruent with the assumptions that are made for research?

The assumptions are congruent with the assumptions that are made for the research in that attitudes, subjective norms, and perceived behavioral control can help explain up to 50% of why help is sought. All hypothesis relationships generated from the theory were found to be statistically significant.

8.

Is the theory oriented to outcomes that are critical to patients?

The theory is oriented to outcomes that are critical to patients. These social cognitive factors were found to be more significant than clinical factors, such as pain severity and disability, than previously thought. The theory allows for the development of an intervention to improve/modify these factors and change healthrelated behavior. There is research to demonstrate that this can impact positively and directly on patient outcomes (e.g., early diagnosis and treatment, and less costly and invasive interventions).

9.

Are tools available to test relationships of the theory or do they need to be developed?

For the current study, a population- and context-specific instrument was developed and pilot tested. Comprehensive guidelines are published by the theorists (Ajzen, 2006; Fishbein & Ajzen, 2010) and experts in instrument development for Theory of Planned Behavior research (Francis et al., 2004).

Based on Fawcett (1999) and adapted for Bredow (2004).

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING Villarruel et al. (2001) make the link between the Theory of Planned Behavior and nursing research, cautioning its use without prior evaluation and integration with nursing theory. That said, numerous nursing studies have successfully utilized the theory; examples include nurses’ intentions to assess pain (Nash et al., 1993); nurses’ intentions to use physical restraint (Werner & Mendelsson, 2001); and nurses’ behavior regarding CPR (cardiopulmonary resuscitation) (Dwyer & Williams, 2002).

USE OF THE THEORY IN THIS RESEARCH Two practical examples of applying the Theory of Planned Behavior in nursing research are provided by the author. Behaviors include help-seeking for chronic pain and influenza vaccine uptake among student nurses.

The Theory of Planned Behavior Applied to Help-Seeking for Chronic Pain The aim of this research is to identify, assess, and enhance understanding of the determinants of HSB for chronic pain using the Theory of Planned Behavior. Untreated chronic pain can have profound physical, psychological, and social effects. Many people with chronic pain do not seek help or have sought help initially but failed to return. Given the nature of chronic pain and the observed patterns of HSB, it is

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important to understand the determinants of engagement in order to develop and improve pain services. Research to date investigating help-seeking for chronic pain has lacked theoretical direction. By virtue of the fact that, conceptually, help-seeking is a planned behavior (­Cornally & McCarthy, 2011b), it is logical to employ the Theory of Planned Behavior. Furthermore, there is substantial recent evidence to support the use of the Theory of Planned Behavior to investigate and explain the factors that influence HSB. There is congruence that attitudes are the strongest predictors of help-seeking intention (Hunter et al., 2003; Mo & Mak, 2009; Schomerus et al., 2009; Steginga et al., 2008; Stogstat et al., 2006; Westerhof et al., 2008). However, disparity is noted regarding the predictability of subjective norms above perceived behavioral control. Steginga et al. (2008) found that the influence of others was a stronger predictor of intention, whereas Hunter et al. (2003) found perceived behavioral control to be the strongest— perhaps this relates to the context. For example, Hunter et al. (2003) were investigating help-seeking for breast cancer symptoms, whereas Steginga et al. (2008) were investigating help-seeking for mental health problems, where stigma is known to reduce HSB. Mo and Mak (2009) and Skogstad et al. (2006) were also investigating HSB for mental health problems and agree that subjective norms were a stronger predictor of intention compared to perceived behavioral control. Conflicting evidence is provided by Westerhof et al. (2008) in relation to subjective norms; however, unlike the previous researchers, they used the Attitudes to Seeking Professional Psychological Help Scale to measure normative beliefs, rather than eliciting salient normative beliefs from the population under investigation, as suggested by Ajzen (2006). Perceived behavioral control demonstrated the weakest correlations with behavioral intention. Perhaps this is owing to the fact that, in all studies, participants were responding to hypothetical situations and were overcautious when estimating the control they might have over the behavior. Or they were not able to account for the external inhibiting factors because the behavior had never been conducted before. It is logical to assume that people who have orchestrated a behavior in the past will have the ability to accurately indicate perceived behavioral control. Overall, studies demonstrated that the variables of the Theory of Planned Behavior explained between 30% and 51% of intentions to seek help, which is highly desirable. For this reason, Mackenzie, Knox, Gekoski, and Macaulay (2004) suggest that the Theory of Planned Behavior is a suitable framework to investigate the factors influencing HSB, acknowledging that many studies on help-seeking are conducted devoid of an appropriate theoretical framework, resulting in the measurement of unrelated concepts. In order to operationalize the constructs of the theory when applied in this context, it was necessary to develop an instrument. This involved a qualitative exploration of help-seeking for chronic pain in which data were collected from people with chronic pain who sought help in the past (n = 25). The qualitative findings from this elicitation study were used to generate items that measured attitudes, subjective norms, perceived behavioral control, and intention to seek help for chronic pain (Table 5.5). In the subsequent quantitative study, data were collected online from people with chronic pain (n = 292) using the newly developed Attitudes, Beliefs, and HelpSeeking Behavior for Chronic Pain (HSB-CP) Questionnaire. This instrument contains 66 items across a number of scales and subscales. The newly developed instrument was pilot tested on a sample of 27 people with chronic pain and retested for temporal stability 2 weeks later (n = 13). Overall,



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Table 5.5 Sample Item Generation subscale

sample participant narrative

Behavioral Beliefs (Expectation either positive or negative about the outcome of seeking help; i.e., advantages/ disadvantages)

example of items generated

“My GP realized that I needed help and he referred me on to the various different specialists, which was tremendous”

Seeking help from a primary health care professional will result in “Being referred to a specialist”

“That I and my story would be listened to in an open way, so that I receive understanding and empathy”

Seeking help from a primary health care professional will result in “Being listened to and understood”

“When they don’t know the answer, it’s either depression or something else and that frustrates me; you get depressed by the way they treat you”

Seeking help from a ­primary health care professional will result in “Feeling worse emotionally”

Normative ­Referents (Normative r­ eferents are those people or groups who either negatively or ­positively influence an individual’s ­help-seeking behavior)

“My family were not supportive; they said,‘Can’t you lie on the floor and you’ll be better’”

My Family thinks I should seek help from a health care professional for my chronic pain

“I have a good friend; she is a nurse and she tells me to get help”

My Friends think I should seek help from a health care professional for my chronic pain

Control Beliefs (Perceived barriers and facilitators for seeking help)

“Joining a support group made it easier for me to get help; I am a bit more informed and that gives me a bit more confidence in talking to the health care professionals”

“Being a member of a support group” would affect whether I seek help

“If I go to the GP he will think it is all in my head”

“Fear of not being believed” would affect whether I seek help

findings supported temporal stability on both the direct and indirect subscales. Satisfactory Cronbach alphas were also achieved. In addition, there were positive correlations between the direct and indirect subscales demonstrating construct validity of both measures. Further psychometric evaluation of the newly developed instrument took place following data collection for the main study (n = 292), indicating positive results. A conceptual framework for exploring help-seeking for chronic pain using the Theory of Planned Behavior was devised; this allowed for hypotheses’ generation (Figure 5.1). A key finding of this study is that the model as a whole explained 54% of the variance in intentions to seek help—and this was significant (p < .001). A key outcome of this study is a theory-driven inventory of the factors influencing intention to seek help for chronic pain. A secondary outcome of this research is an instrument to measure the constructs of the Theory of Planned Behavior when applied to help-seeking for chronic pain.

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Part II  Theories Applied to Research Figure 5.1  Conceptual framework demonstrating the hypothesized relationship among the independent variables, both direct and indirect (attitudes, subjective norms, perceived behavioral control); the dependent variable (behavioral intention); and the status variables. Independent and dependent variables are measured using the newly developed HSB-CP Questionnaire. Independent Variables

Dependent Variable

Status Variables

Attitudes Indirect Attitudes (Behavioral Beliefs) Outcome expectancy

Direct Attitudes

Outcome

X evaluation Subjective Norm

Indirect Subjective Norms (Normative Beliefs) Normative expectation

Motivation

X to comply

Direct Subjective Norms

Behavioral Intention

• Demographic questionnaire (age, gender, time since onset of pain, cause of pain, attending pain specialist, membership of a support group) • Past help-seeking behavior • Pain grade (intensity and disability)

Perceived Behavioral Control Indirect Perceived Behavioral Control (Control Beliefs) Presence of control beliefs

Perceived power of

Direct Perceived Behavioral Control

X control beliefs

Source: Cornally (2012).

The Theory of Planned Behavior Applied to Influenza Vaccine Uptake Among Student Nurses The author also applied the theory to vaccination uptake among student nurses (Cornally, Deasy, McCarthy, Moran, & Weathers, 2013). This study was conducted using the predictor variables only and was exploratory in nature. The aim of this research was to investigate the uptake of influenza vaccination among student nurses and explore reasons for either declining or accepting it in the past. In addition, this research aimed to establish if, and to what extent, the constructs proposed by the Theory of Planned Behavior predict vaccination behavior among student nurses. A descriptive quantitative and correlational design was used. Data were collected using a researcher-developed questionnaire that contained a section with four scales to represent the constructs of the Theory of Planned Behavior (attitudes, subjective norms, perceived behavioral control, and intention). All final-year student nurses (n = 218) in one university in the south of Ireland were invited to participate. In total, 131 questionnaires were completed. In order to determine how much variance in intention scores can be explained by attitude, subjective norm, and perceived behavioral control, collectively, regression analysis was conducted. Overall, the model explained 41.9% of the variance in intention. A positive attitude and perceived pressure from employers and their profession were also highlighted as predictors of intention to vaccinate. It is recommended, therefore, that any future intervention would benefit from a framework that addresses each aspect of the Theory of Planned Behavior.



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RECOMMENDATIONS FOR FURTHER RESEARCH The Theory of Planned Behavior is well established as a suitable framework for investigating and exploring human behavior. It is recommended that future researchers investigating HSB employ the Theory of Planned Behavior above other theories, such as Andersen and Newman’s Behavioral Model of Health Service Utilization (1973) and the Health Belief Model (Rosenstock, 1966), because a number of studies (e.g., Bish, Sutton, & Golombok, 2000; Quine, Rutter, & Arnold, 1998) have demonstrated that the Theory of Planned Behavior has greater predictive power than the Health Belief Model. Also, in terms of Andersen and Newman’s model, the Theory of Planned Behavior has a superior focus on the psychosocial influences of HSB that were identified as important in a concept analysis of HSB (Cornally & McCarthy, 2011). Finally, neither Andersen and Newman’s model nor the Health Belief Model provide sufficient empirical guidance regarding the relationships between variables or subsequent appropriate hypotheses formulation and testing, unlike the Theory of Planned Behavior (Vernberg, 1998). Extending the Theory of Planned Behavior to include concepts such as self-­ efficacy has been recommended (Giles, McClenahan, Cairns, & Mallet, 2004), and others also argue that the model does not address emotional aspects such as fear, anger, and so on. Perhaps future neotheoretical frameworks should be devised to include these concepts as they relate to the research question. Finally, it is essential to develop an instrument to measure the beliefs and expectations of the population toward the target behavior, when applying the Theory of Planned Behavior to a new area of investigation. This can be challenging, especially to researchers with little or no experience in the area of instrument development. Although Francis et al. (2004), Ajzen (2006), and Fishbein and Ajzen (2010) have published guidelines, there is a clear need for future research to focus on instrumentspecific issues such as scaling, scoring and validity, as well as reliability issues for Theory of Planned Behavior questionnaires. This should allow for more robust evaluation of existing instruments and aid novice researchers when devising their own questionnaires.

SUMMARY This chapter presents an outline of the Theory of Planned Behavior, its development over time, and its utility both within the discipline of nursing and across other disciplines (e.g., science and technology). A rudimental evaluation on how the theory links to nursing metaparadigms reveals that potential integration is possible. However, Villarruel et al. (2001) recommends further research to ensure the suitability of borrowed theories. An evaluation and analysis of the theory based on the work of Fawcett (1999) adapted for Bredow (2004) demonstrates support for the theory. A description of how the theory is applied to HSB and vaccination serves to demonstrate its broad scope and illustrate to researchers ways of approaching a Theory of Planned Behavior study. As a final point, areas for further research in theory expansion and instrument development are outlined. It is evident that the theory has and can be diversely applied to investigate, explain, and predict any aspect of planned human behavior.

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REFERENCES Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhi & J. Beckmann (Eds.), Action-control: From cognition to behavior (pp. 11–39). Heidelberg, Germany: Springer. Ajzen, I. (1991). The Theory of Planned Behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. Ajzen, I. (2002). Perceived behavioral control, self-efficacy, locus of control, and the Theory of Planned Behavior. Journal of Applied Social Psychology, 32, 665–683. Ajzen, I. (2006). Constructing a Theory of Planned Behavior questionnaire: Conceptual and methodological considerations. Retrieved from: http://www.people.umass.edu/ aizen/pdf/tpb.measurement.pdf Ajzen, I., & Fishbein, F. (2008). Scaling and testing multiplicative combinations in the Expectancy Value Model of attitudes. Journal of Applied Social Psychology, 38, 2222–2247. Andersen, R., & Newman, J. F. (1973). Societal and individual determinants of medical care utilisation in the United States. The Milbank Memorial Fund Quarterly. Health and Society, 51(1), 95–124. Armitage, C., & Christian, J. (2003). From attitudes to behaviour: Basic and applied research on the Theory of Planned Behaviour. Current Psychology: Developmental, Learning, Personality, Social, 22(3), 187–195. Armitage, C., & Conner, M. (2001). Efficacy of the Theory of Planned Behaviour: A meta-­ analytical review. British Journal of Social Psychology, 40, 471–499. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioural change. Psychological Review, 84(2), 191–215. Bennett, I. M., Palmer, S., Marcus, S., Nicholson, J. M., Hantsoo, L., Bellamy, S., . . . Coyne, J. C. (2009). “One end has nothing to do with the other”: Patients attitudes regarding help seeking intention for depression in gynecologic and obstetric settings. Archives of Women’s Mental Health, 12, 301–308. Bish, A., Sutton, S., & Golombok, S. (2000). Predicting uptake of a routine cervical smear test: A comparison of the health belief model and the theory of planned behaviour. Psychology and Health, 15(1), 35–50. Bredow, T. S. (2004). Analysis, evaluation and selection of a middle range nursing theory. In S. J. Peterson & T. S. Bredow (Eds.), Middle range theories: Application to nursing research (pp. 42–56). Philadelphia, PA: Lippincott Williams & Wilkins. Bryan, A., Fisher, J. D., & Fisher, W. A. (2002). Tests of the mediational role of preparatory safer sexual behavior in the context of the Theory of Planned Behavior. Health Psychology, 21(1), 71. Conner, M., & Armitage, C. J. (1998). Extending the Theory of Planned Behaviour: A review and avenues for further research. Journal of Applied Social Psychology, 28(15), 1429–1464. Cornally, N. (2012). Understanding the determinants of help-seeking Behavior for chronic pain: A study underpinned by the theory of planned behavior. Unpublished Thesis (PhD) –NUI, at Department of Nursing and Midwifery, University College Cork. Cornally, N., Deasy, E. A., McCarthy, G., Moran, J., & Weathers, E. (2013). Student nurses’ intention to get the influenza vaccine. British Journal of Nursing, 22(21), 1207–1211. Cornally, N., & McCarthy, G. (2011). Help-seeking behavior: A concept analysis. International Journal of Nursing Practice, 17(3), 280–288. Côté, F., Gagnon, J., Houme, P. K., Abdeljelil, A. B., & Gagnon, M. P. (2012). Using the Theory of Planned Behavior to predict nurses’ intention to integrate research evidence into clinical decision‐making. Journal of Advanced Nursing, 68(10), 2289–2298.



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Davis, L. E., Ajzen, I., Saunders, J., & Williams, T. (2002). The decision of African American students to complete high school: An application of the Theory of Planned Behavior. Journal of Educational Psychology, 94(4), 810. Dwyer, T., & Mosel Williams, L. (2002). Nurses’ behaviour regarding CPR and the theories of reasoned action and planned behaviour. Resuscitation, 52(1), 85–90. Edwards, H. E., Nash, R. E., Najman, J. M., Yates, P. M., Fentiman, B. J., Dewar, A., . . . Skerman, H. M. (2001). Determinants of nurses’ intention to administer opioids for pain relief. Nursing & Health Sciences, 3(3), 149–159. Elliott, M. A., Armitage, C. J., & Baughan, C. J. (2007). Using the Theory of Planned Behavior to predict observed driving behavior. British Journal of Social Psychology, 46(1), 69–90. Fawcett, J. (1999). The relationship of theory and research. Philadelphia, PA: F.A. Davis Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (2nd ed.). Philadelphia, PA: F. A. Davis. Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention and behaviour. An introduction to theory and research. Boston, MA: Addison-Wesley. Retrieved October 10, 2009, from http:// people.umass.edu/aizen/f&a1975.html Fishbein, M., & Ajzen, I. (2010). Predicting and changing behavior: The reasoned action approach. New York, NY: Psychology Press. Francis, J. J., Eccles, M. P., Johnston, M., Walker, A. E., Grimshaw, J. M., Foy, R., & Bonetti, D. (2004). Constructing questionnaires based on the Theory of Planned Behaviour. A manual for health services researchers. Retrieved from http://pages.bangor.ac.uk/~pes004/exercise_ psych/downloads/tpb_manual.pdf Gálvez, C. A., Modeste, N., Lee, J. W., Betancourt, H., & Wilkins, R. L. (2002). Peruvian mothers’ knowledge and recognition of pneumonia in children under 5 years of age. Pan American Journal of Public Health, 11(2), 99–108. Giles, M., & Cairns, E. (1995). Blood donation and Ajzen’s theory of planned behavior: An examination of perceived behavioral control. British Journal of Social Psychology, 34(2), 173–188. Giles, M., McClenahan, C., Cairns, E., & Mallet, J. (2004). An application of the Theory of Planned Behaviour to blood donation: The importance of self-efficacy. Health Education Research, 19(4), 380–391. Giles, M., & Rea, A. (1999). Career self‐efficacy: An application of the Theory of Planned Behavior. Journal of Occupational and Organizational Psychology, 72(3), 393–398. Hunter, M. S., Grunfeld, E. A. & Ramirez, A. J. (2003). Help-seeking intentions for breast-cancer symptoms: A comparison of the self-regulation model and the Theory of Planned Behavior. British Journal of Health Psychology, 8, 319–333. Mackenzie, C. S., Knox, V. J., Gekoski, W. L., & Macaulay, H. L. (2004). An adaptation and extension of the attitudes towards seeking professional psychological help scale. Journal of Applied Social Psychology, 34, 2410–2435. Mirkuzie, A. H., Sisay, M. M., Moland, K. M., & Åstrøm, A. N. (2011). Applying the Theory of Planned Behavior to explain HIV testing in antenatal settings in Addis Ababa—A cohort study. BMC Health Services Research, 11(1), 196. Mo, P. K. H., & Mak, W. W. S. (2009). Help-seeking for mental health problems among Chinese: The application and extension of the Theory of Planned Behavior. Social Psychiatry and Psychiatric Epidemiology, 44, 675–684. Nash, R., Edwards, H., & Nebauer, M. (1993). Effect of attitudes, subjective norms and perceived control on nurses’ intention to assess patients’ pain. Journal of Advanced Nursing, 18, 941–947. Nooijer, J. D., Lechner, L., & Vries, H. D. (2003). Social psychological correlates of paying attention to cancer symptoms and seeking medical help. Social Science and Medicine, 56, 915–920.

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Part II  Theories Applied to Research Ogden, J. (1996). Health psychology: A textbook. Buckingham, UK: Open University Press. Quine, L., Rutter, D. R., & Arnold, L. (1998). Predicting and understanding safety helmet use among schoolboy cyclists: A comparison of the theory of planned behavior and the health belief model. Psychology and Health, 13(2), 251–269. Rosenstock, I. M. (1966). Why people use health services. The Milbank Memorial Fund Quarterly. Part 2, 44(3), 94–127. Ross, L., Kohler, L. C., Grimley, D. M., & Anderson-Lewis, C. (2007). The theory of reasoned action and the intention to seek cancer information. American Journal of Health Behavior, 31(2), 123–134. Schomerus, G., Matschinger, H., & Angermeyer, C. (2009). Attitudes that determine willingness to seek psychiatric help for depression: A representative population survey applying the Theory of Planned Behavior. Psychological Medicine, 39, 1855–1865. Shih, Y. Y., & Fang, K. (2004). The use of a decomposed Theory of Planned Behavior to study Internet banking in Taiwan. Internet Research, 14(3), 213–223. Skogstad, P., Deane, F. P., & Spicer, J. (2006). Social-cognitive determinants of help-seeking for mental health problems among prison inmates. Criminal Behavior and Mental Health, 16(1), 43–59. Steginga, S. K., Campbell, A., Ferguson, M., Beeden, A., Walls, M., Cairns, W., & Dunn, J. (2008). Socio‐demographic, psychosocial and attitudinal predictors of help seeking after cancer diagnosis. Psycho‐Oncology, 17, 997–1005. Triandis, H. C. (1980). Values, attitudes, and interpersonal behavior. In H. Howe & M. Page (Eds.), Nebraska symposium on motivation (pp. 195–259). Lincoln: University of Nebraska Press. Vernberg, D. (1998). Sociomedical model and the epistemology of risk: The shortcomings of medical decision making. In J. T. Pardeck, C. F. Longino, & J. W. Murphy (Eds.), Reason and rationality in health and human service delivery (pp. 32–48). New York, NY: The Haworth Press. Villarruel, A. M., Bishop, T. L., Simpson, E. M., Jemmott, L. S., & Fawcett, J. (2001). Borrowed theories, shared theories, and the advancement of nursing knowledge. Nursing Science Quarterly, 14(2), 158–163. Werner, P., & Mendelsson, G. (2001). Nursing staff members’ intentions to use physical restraints with older people: Testing the theory of reasoned action. Journal of Advanced Nursing, 35(5), 784–791. Westerhof, G. J., Maessen, M., de Bruijn, R., & Smets, B. (2008). Intentions to seek (preventive) psychological help among older adults: An application of the Theory of Planned Behavior. Aging and Mental Health, 12, 317–322. Wicker, A. W. (1969). Attitudes versus actions: The relationship of verbal and overt behavioral responses to attitude objects. Journal of Social Issues, 25, 41–78.

chapter 6

Social Support Theory Patricia Leahy-Warren

Social support is considered a middle range theory that focuses on relationships and the interactions within those relationships. The importance of social relationships in contributing to health and well-being has been the focus of research by scientists and practitioners across a large number of social, behavioral, medical, and nursing disciplines (Cohen, Underwood, & Gottlieb, 2000). Social support is often used in a broad sense, usually referring to any process through which social relationships might enhance health and well-being. However, there is a lack of consensus on the conceptualization and definition of social support (Hupcey, 1998a). Researchers and theorists disagree on the dimensionality of social support (Langford, Bowsher, ­Maloney, & Lilles, 1997) and a considerable number of social support instruments have been used to evaluate support in specific situations. This lack of consensus contributes to complexity in evaluating social support interventions and outcomes, comparing research findings, and developing Social Support Theory (Schaffer, 2004). Social Support Theory is important to nursing and midwifery because it impacts on health behavior, health status, and use of health services (Stewart, 1993).

BASIC DESCRIPTION OF THE THEORY Conceptualized in social terms, support is the natural consequence of relationships involving certain types of interactions. Social support frequently refers to the process through which social relationships promote health and well-being. The term social support was first coined by Cassel (1976); based on his research with animals, he theorized that strengthening social support could positively influence the health of humans. Both Cassel (1976) and Cobb (1976) referred to the cushioning effect of social support in preventing or relieving stress. This is often referred to as the buffer theory. Cobb (1976) argues that major life transitions put people at risk for stress and ill health both physically and psychologically. He asserts that information leading the person to believe that she or he is cared for and loved, held in esteem, and belongs to a network of communication is a form of social support and protects the person from stress. He believes that the people perceiving these interactions are facilitated to cope and adapt appropriately. The research review of correlation studies undertaken by Cohen and Wills (1985) concluded

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that perceived availability of social support is more important for health and well-being than actual receiving of support. Social support has been examined by multidisciplinary researchers such as sociologists, psychologists, and nurses. Sociologists refer to social network participation or social integration and generally mean the diversity of relationships in which people participate. Typically, these relationships may include those with spouse, siblings, friends, neighbors, work or religious groups; the general consensus from the research was that the greater the participation and the larger the society, the better the health outcomes (Cohen & Wills, 1985; House, 1981). However, there continues to be debate as to which characteristics of social networks are essential to health: the level of integration as measured by the diversity of range of relationships (Cohen & Syme, 1985) or involvement in a range of social activities (House, 1981). During the period of 1970 through 1980, social support was described in terms of a process, interaction, person, or relationship (Veiel & Baumann, 1992). Recently, it has been described more abstractly, using such terms as perceptions, quality, quantity of supportive interactions, behaviors, and social systems (Hupcey, 1998a). The diversity of what is subsumed under the term social support, as evident from above, requires the identification of the core concepts.

CORE CONCEPTS Theorists, researchers, and practitioners have acknowledged the challenges experienced in defining, conceptualizing, and measuring social support (Hupcey, 1998a, 1998b; Stewart, 1993). There are many and varied terminologies presented in the literature pertaining to social support. These include interpersonal transactions (Khan & Antonucci, 1980); defining attributes (House, 1981); subconcepts (Barrera, 1986); types (Norbeck, Lindsey, & Carrieri, 1983; Wortman, 1988); constructs (Vaux, 1988); dimensions (Cutrona, 1990); aspects (Cohen, 1992); and categories (Hupcey, 1998). In her analysis of Social Support Theory, Hupcey (1998) identified five categories within the major theoretical definitions: (a) social networks, (b) perceptions of support, (c) behaviors of the provider, (d) reciprocal support, and (e) types of support provided. Within these varying definitions, there is general consensus that the positive interaction or helpful behavior is common to all definitions. Social networks have been defined as the social connections provided by the environment (Doeglas et al., 1996) and are the vehicle through which social support is provided (Langford et al., 1997). According to Doeglas et al. (1996), structural networks consist of a set of properties such as density, reciprocity, sex composition, and homogeneity of one’s network. Oakley (1992) takes this a step further and suggests that social networks in themselves provide shared norms, values, and ideologies, whereas individual relationships lack this collective consensual element. Thus, the interconnectedness among network members then becomes potentially a feature of the social support available to any individual. This is not to suggest that individuals within a social network cannot provide social support in an individual capacity. Rather, it is proposing that individuals do not live in isolation; thus, making connections with one individual should lead to a larger interconnected social network. It would appear that a social network is an interactive field of persons who provide the mutual aid of helpfulness and protection. Thus, a social network is the structure of the interactive process and individuals within this network are the sources. Sources of support within the context of postnatal care are found predominantly to be informal caregivers such as a mother’s partner/husband, mother, grandparents,



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family and friends, and support groups in the context of breastfeeding (Cronenwett, 1985a, 1985b; Hoddinott, Britten, Prescott, Tappin, & Godden, 2009; Leahy-Warren, 2005, 2007; Podkolinski, 1998). Relationships involving social exchange are not required to be of an intimate nature; research from the area of self-disclosure provides an insight into the benefits of support exchanges. This exchange may occur between a recipient and a stranger, such as an expert in a particular field (e.g., a therapist, a solicitor, or a nurse). S ­ humaker and Brownell (1984) argue that some people may prefer to obtain assistance from a stranger or a professional support provider because this may lessen their sense of indebtedness felt when receiving support from close social networks. Within the process of social exchange or reciprocity is the feeling of belonging, and this is achieved by comparing oneself with others in a similar situation. Social comparison theory explains how persons develop their self-concept by comparing themselves to others in their chosen reference groups. This may involve comparing their opinions, attitudes, and beliefs, which Stewart (1993) suggests enhances coping abilities, emotional adjustment, self-esteem, and psychological well-being (Langford et al., 1997). Within House’s (1981) definition, appraisal support appears to be conducive to being attained within social comparison opportunities in particular. The “network of communication” within Cobb’s (1976) definition suggests social comparison, whereas Khan and Antonucci’s (1980) affirmation category includes the appropriateness or rightness of some act that represents social comparison. Social comparison and the giving and receiving of social support imply some degree of social competence. Social competence is thought to be essential to the formation and preservation of relationships, a necessary component of social health. This would seem to indicate that social support could not occur unless there is some form of social competence, where the recipient and the provider are both in a position of a positive social climate of assistance and protection (Langford et al., 1997). It is within a positive social climate of assistance and safety that the previous definitions of social support—underpinned by the theories of social exchange, social comparison, and social competence—operate. Supportive interactions are objective transactions of social support, whereas the perceptions of being supported are very much of subjective quality. Perceiving certain interactions as being supportive is based on the needs of the recipients, as well as their expectations with respect to those needs. Barrera (1986) would argue that perceived social support has emerged as a prominent concept that characterizes social support as “the cognitive appraisal of being reliably connected to others” (p. 416). This differs from social embeddedness in that it is not so much the number of supporters or the amount of social contacts, but the individual’s confidence that adequate support would be available if needed. Social supportive behaviors cannot occur unless there is a structure of social networks with the quality of connectedness in a favorable environment of assistance and safety. Thus, this favorable environment is regarded as a social climate, which is a necessary attribute of social support. Although it is important to identify the sources of support within an individual’s social network that move beyond the quantification of social ties, it is also necessary to identify the interactions that occur within the process (Brandt & Weinert, 1981; Norbeck et al., 1981). It appears from the literature reviewed on social support that within a positive social climate, underpinned by its theoretical foundations, there are four types or

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functions of social support: informational, emotional, instrumental, and appraisal support (Barrera, 1986; Cronenwett, 1983; House, 1981; Khan & Antonucci, 1980; ­Tilden & Weinert 1987). Informational support means providing an individual with information, advice, and directives that the individual can use in coping with personal and environmental problems. Thus, the information given to the recipients must be relevant to those persons in their present circumstances. Cronenwett (1983) suggests that informational support assists an individual in decision-making operations, and thus helps individuals to help themselves. Fichardt, van Wyk, and Weich (1994) found the greatest number of needs and problems for new mothers (n = 40) two weeks postpartum were related to self-concept, such as low self-esteem and dissatisfaction with body image. They concluded that greater informational support was necessary during this developmental phase of the postpartum period to enable mothers to cope with their personal and environmental problems. Cobb’s (1976) definition of social support seems to have its foundations on informational support, which encompasses some of the other defining attributes of social support such as emotional and appraisal support. Within this definition, the implication is that information is the cornerstone of social support and therefore the most important element. However, the distinction is made among different types of social support; focusing on only one type could be considered unduly restrictive. House (1981) argues that no one type of social support should be considered more important than another. Just as the relevance of sources of support varies with an individual and problem requiring support, so would the relevance of different types of support. Nevertheless, House (1981) presents emotional support as the most important category through which the perception of support is conveyed to others. Gottlieb (1978) asked single mothers (n = 40) in a semistructured interview about their sources of support and the types of support provided. Emotional support was found to be the largest number of specific acts of support reported. Emotional support is delineated as those acts that provide empathy, concern, caring, love, and trust. Emotional support is the transfer of some form of caring attributes to an individual. This could be in the guise of providing comfort either of a physical or a psychological nature. Findings from a qualitative study of new mothers (n = 10) indicated that emotional support, particularly from the baby’s father, was very important to them (Podkolinski, 1998). They thought it was important to have someone to share their feelings at the time when everything was so new. Instrumental support is characterized as access to behaviors that directly help the person in need, such as aid in money, time, or labor. It is considered to be concrete assistance or tangible aid (Barrera, 1986; Cronenwett, 1983; House, 1981; Tilden & Weinert, 1987). Barrera (1981) describes tangible assistance as material and physical assistance, whereas Norbeck et al. (1981) use the label aid, and Power and Parke (1984) employ the label physical. The common denominator within these labels is the provision of instrumental support in the guise of hands-on help. New mothers have indicated the importance of having someone to help them with caring for the baby and with household chores (Bennett, 1981). Appraisal support is identified as the transmission of information relevant to self-evaluation, which may be derived from affirmation, feedback, and social comparison opportunities. What House (1981) describes as appraisal support existed as feedback and social participation for Barrera (1986) or ideological support for



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Power and Parke (1984). This form of support mirrors the characteristics of Social Comparison Theory previously mentioned. Appraisal support or comparison support means some type of communication of expectations, evaluations, and shared world views with individuals in a similar position. This dimension is crucial in the development or enhancement of individuals’ self-esteem and self-confidence, enabling them to cope with stress throughout their life cycle. This is of immense importance to first-time mothers in the postpartum period. In their qualitative study, Barclay, Everett, Rogan, Schmied, and Wyllie (1997) indicated that first-time mothers (n = 55) found it helpful to share their experiences with other mothers in a similar situation. In this way, they were able to share their sense of incompetence and feel it was acceptable in their given situation. House (1981) conceptualized social support in terms of activities that are instrumental, informational, and emotional, and features appraisal support.

RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS THEORY Social support has been examined by multidisciplinary researchers such as sociologists, psychologists, and nurses. Social support in health and chronic illness has been one of the most frequently researched concepts in the past decades, both as a coping resource (Cohen et al., 2000) and as a protective factor related to stress and coping (Lazarus & Folkman, 1984). Social support is associated positively with the survival time of cancer patients, independent of other predictors of survival (McLean, 1995; Stang & Mittelmark, 2008). A participatory action research study of professionally led self-help groups for women recovering from breast cancer showed that the social support provided and the implementation of empowerment perspectives overshadowed the negative experiences (Stang & Mittlemark, 2008). Similar findings were reported in a review by Decker (2007) on adolescent cancer survivors, but the providers were parents and friends. A systematic review revealed that only 1 of the 10 trials identified for the review was able to demonstrate a signifi­ cant, positive effect on mood status associated with receipt of a social support intervention for patients following a stroke (Salter, Foley, & Teasell, 2010). Social support strategies are effective for physical activity promotion in those living with diabetes (Karlsen, Idsoe, Hanestad, Murberg, & Bru, 2004; Plotnikoff et al., 2008); however, Molloy, Dixon, Hamer, and Sniehotta (2010) demonstrated—only in their health promotion research—a significant interaction between social support and physical activity for women. Social support also has an important health-promoting function in smoking cessation (Hancock, Perkins, McClintock, Howley, & Gibberd, 2001). Asay and Lambert (1999) suggest that the benefit of intimate relationships provides an even greater influence, as was found in Holmefjord and Mittelmark’s (2009) study. Studies reviewed herein have examined social support; however, many of them have not identified clearly their operational definitions or their conceptualization of social support. Some have measured social networks only (Decker, 2007; Plotnikoff et al., 2008; Stang & Mittlemark, 2008); social integration (Holmefjord & Mittelmark, 2009); nonspecific functional dimensions (Molloy et al., 2010); specific functional dimensions (Hughes et al., 2003); perceived specific functional supports (Bakan & Akyol, 2008); and negative interpersonal interaction/stress (Stang & Mittlemark, 2008).

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RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS According to Stewart and Tilden (1995), nurse scientists have contributed to the development of social support both from a conceptual and theoretical perspective since its inception in the early 1970s. Social support has contributed to clinicians’ and scientists’ understanding of health behaviors, ability to attain and sustain health, and capacity to cope with stress and ill health (Hupcey, 1998a, 1998b; Schaffer, 2004). The metaparadigm of nursing is made up of four concepts: person, environment, health, and nursing. Because social support is essentially an interpersonal process, Brownell and Schumaker (1984) argue that social support is the assistance and protection given to individuals; thus, the person is central to the theory. The giving and receiving of social support imply some degree of social competence. Social competence is thought to be essential to the formation and preservation of relationships, and is a necessary component of social health. This would seem to indicate that social support could not occur unless there was some form of social competence, where the recipient and the provider are both in a position of a positive social climate of assistance and protection (Langford et al., 1997). It is within a positive social climate of assistance and safety that Social Support Theory operates within a positive social environment. Laireiter and Baumann (1992) postulate that social environment is an essential component of social support, whereas Veiel and Baumann (1992) suggest that social support is a characteristic of the person separate from the social interaction, although the person is influenced by the social environment. The positive link between social support and physical health, where persons are integrated with a social network, has been shown to protect health and promote physical and psychological recovery from illness (Uchino, 2009), such as cardiovascular disease (CVD) (Bakan & Akyol, 2008) and depression following stroke (Claiborne, 2006). The final concept of the metaparadigm is nursing, which has a long association with social support from clinical (Leahy-Warren, 2005, 2007; Olds et al., 1999); research (Bakan & Akyol, 2008); and theoretical (Hupcey, 1998; Stewart & Tilden, 1995) perspectives. Norbeck (1981) proposed a specific model for using social support as a nursing intervention to improve health outcomes, where the social environment of the patient was assessed by determining the need for social support compared to available social support. Inadequate social support identified was addressed by developing an intervention to increase social support. According to this model, adequate social support should result in positive health outcomes, whereas inadequate social support should result in negative health outcomes.

THEORY ANALYSIS Using Fawcett’s (1999, 2005) theory evaluation criteria (Table 6.1), Social Support Theory is analyzed along with similar analysis specific to this author’s research. Fawcett (2000) identified the following areas to be considered when evaluating a theory: significance, internal consistency, parsimony, testability, empirical adequacy, and pragmatic adequacy. Significance is assessed by determining if the theory is explicit in addressing the metaparadigm of nursing. This has been addressed in the previous section, where there is evidence that all aspects of the metaparadigm of nursing are addressed within Social Support Theory. Whereas there is acknowledgment within the literature that diversity exists on the concepts of social support, there is general consensus that the fundamental philosophical claims of social support as



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having a positive effect on health status, health behaviors, and health services also exist (Cohen et al., 2000; Schaffer, 2004; Stoltz, Udén, & W ­ illman, 2004). The diversity of the concepts within the model is explicit, and antecedent knowledge is well recognized from nursing (Hupcey, 1998; Norbeck, 1981; Schaffer, 2004) and other health disciplines (Cohen et al., 2000; House, 1981). Table 6.1 Evaluative Criteria and Use of Social Support Theory in the Study Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

Although there are many and varied theoretical definitions of social support, Social Support Theory is important to nursing and midwifery because it impacts on health behavior, health status, and use of health services (Stewart, 1993). The aim of this study is to identify and examine social support, maternal parental self-efficacy, and postpartum depression in first-time mothers at three time periods, and to explore the relationships among these variables.

2.

Is it readily operationalized?

Social support is readily operationalized once the researcher has a definitive research question and clearly identifies the concepts under measurement and how they are defined. For this study, social support is conceptualized in terms of structural and functional dimensions, both of which are inextricably linked. Structural supports refer to the individual’s social network, such as friends, acquaintances, relatives (known as informal), and professionals (formal). Functional aspects of social support refer to the exchange activities (i.e., informational, instrumental, emotional, and appraisal support).

3.

How well has the theory performed at describing, predicting, and/ or explaining the phenomena to which it relates?

The theory has been used in nursing to describe and explain patient-environment interactions for specific contexts, such as transitions (parenthood, motherhood, long-term care, bereavement, chronic illness). It has been previously used to explain the relationship between social support provided by public health nurse home visits and an increase in positive self-care practices and child well-being for participating mothers (Olds et al., 1999).

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

The theory relates to and addresses the research hypotheses in its description and explanation of the relationship between structural and functional social support, as well as the mothers’ postnatal birth depression at 6 weeks and 12 weeks postdelivery.

5.

Does the theory flow from the research question?

The research question has the potential to expand knowledge relating to the structures (social network) and functions (informational, instrumental, emotional, and appraisal support) perceived by first-time mothers in the postpartum period, as well as the relationship between these concepts and postpartum depression. Therefore, the theory guided the development of the research question and hypotheses. (continued)

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Table 6.1 Evaluative Criteria and Use of Social Support Theory in the Study (continued) Questions for evaluation

Responses to questions

6.

Does the theory address the primary and secondary research questions?

The theory addresses the primary and secondary research questions (i.e., to describe first-time mothers’ perceived social support structures and functions, and investigate the relationship between these concepts and postpartum depression at three time points.

7.

Are the assumptions congruent with the assumptions that are made for research?

The assumptions are congruent with the assumptions that are made for the research; the assumption is that support is given and received by members of a social network, leading to feelings of belonging and thus positive health outcomes for the recipient.

8.

Is the theory oriented to outcomes that are critical to patients?

The theory is oriented to outcomes that are critical to mothers. It allows for mothers’ individual experiences of social support received to be ascertained and the relationship between these perceived supports and level of risk of postpartum depression.

9.

Are tools available to test relationships of the theory or do they need to be developed?

Because the current study conceptualizes social support as having both structural and functional components, a previously designed instrument developed by the researcher was further developed for this study to measure structural and functional components of social support in the context of infant-care practices in the postpartum period (Perinatal Infant Care Social Support [PICSS] Scale) (Leahy-Warren, McCarthy, & Corcoran, 2011, 2012).

Based on Fawcett (1999) and adapted for Bredow (2004).

Fawcett and colleagues’ (2001) next criterion of internal consistency is assessed by ensuring congruency among concepts, context, and semantics. Social support is a multifaceted concept that has led to difficulties with definition, conceptualization, and operationalization (Cohen et al., 2000; Hupcey, 1998; Schaffer, 2004). Nevertheless, there is consistency between the concepts and semantics used to describe them. There are many and varied contexts in which social support is utilized; therefore, it is difficult to determine consistency. Parsimony is concerned with whether the theory is stated clearly and concisely. Social Support Theory is stated neither clearly nor concisely because there are a number of theoretical definitions; therefore, it does not fulfill this criterion of evaluation. There are many and varied instruments designed by several disciplines to measure social support; however, according to Schaffer (2004), many do not have robust psychometric properties. Furthermore, some are contextspecific, as recommended by Barrera (1986), and others are general measures such as the Norbeck Social Support Questionnaire (NSSQ) (Norbeck et al., 1981, 1983). S ­ tewart (1989) undertook a review of 21 social support instruments of which only 4 were general measures. The most frequently used and psychometrically sound measures in nursing identified by Schaffer (2004) are the InterPersonal Relationship Inventory (IPRI) (Tilden, Nelson, & May, 1990); the NSSQ (Norbeck et al., 1983); the Perceived Resource Questionnaire (PRQ) (Weinert, 1987); and the Social Support in Chronic



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Illness Inventory (SSCII) (Hilbert, 1990). The first three instruments are general measures, whereas the Support Behaviours Inventory (SBI) (Brown, 1986) is specific to pregnancy and the latter is specific to persons with chronic illness (Schaffer, 2004). The next step of Fawcett and associates’ (2001) evaluation process is empirical adequacy, which requires that assertions made by the theory are congruent with empirical evidence found using the theory as a basis for research. A number of nursing research studies using Social Support Theory have demonstrated congruence, in that the outcome is having a positive effect on health status, health behaviors, and health services (Schaffer, 2004). Norbeck (1981) proposed a nursing model of social support where an individual’s social support resources were assessed and, if deemed lacking, a nursing intervention was introduced to improve health outcomes for that individual. It is one of the most frequently used measures in nursing research and has been used in more than 250 studies published in peer-reviewed journals (Gigliotti & Samuels, 2011). The final step of Fawcett and colleagues’ (2001) evaluation process is the criterion of pragmatic adequacy, which is the extent of how well this Social Support T ­ heory is utilized in clinical practice. Nurses and midwives have the knowledge, skills, and competencies to assess an individual’s social support availability, design appropriate interventions, implement them, and evaluate them appropriately (Schaffer, 2004). Nurses and midwives have frequent and regular contact and communications with patients, their families, and significant others. Nurses can assess, mobilize, and intervene to strengthen social support to positively influence patient health outcomes.

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING Social support interventions have been used in nursing and midwifery in many and varied clinical settings. Nursing and midwifery research have explored a diversity of clinical practice issues from a social support perspective. Social support in chronic illness in nursing has been featured, particularly in the areas of stroke (Salter et al., 2010); cancer (Stang et al., 2008); and heart disease (Kristofferzon, Löfmark, & Carlsson, 2003). From a community perspective, social support has been investigated in conjunction with other variables such as quality of life and pain in patients with leg ulcers (Edwards, Courtney, Finlayson, Shuter, & Lindsey, 2009). With regard to pregnancy and childbirth, research on social support has been undertaken on a variety of nursing and midwifery clinical practice contexts. These include breastfeeding (Hauck, Fenwick, Dhaliwal, Butt, & Schmied, 2011); first-time mothers (Leahy-­Warren, 2005, 2007); birthing (Hodnett et al., 2002); and the postnatal period (Olds et al., 2004). However, research investigating social support, maternal parental self-efficacy, and postnatal depression in the context of first-time mothers underpinned by theoretical assumptions was lacking.

USE OF THE THEORY IN THIS RESEARCH Based on the theoretical and empirical literature reviewed and on the aim of the author’s research, a conceptual framework to guide the study was developed to investigate social support, maternal parental self-efficacy, and postnatal depression

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and associated relationships. The framework is composed of three major concepts: social support, maternal parental self-efficacy, and postnatal depression in the context of first-time mothers in the postnatal period. Given that the focus of this research is the transition to motherhood, which can be viewed as a psychosocial process, the psychosocial perspectives of social exchange theory (Blau, 1964; Homans, 1961); self-efficacy theory by Bandura (1997); and the social, economic, and medical perspectives of postnatal depression were drawn on to construct a conceptual framework to underpin this study. The conceptual framework (Figure 6.1) illustrates the relationships among social support, maternal parental selfefficacy, and postnatal depression. Social Support Theory is concerned with the exchange of activity between at least two people. This interaction can cover a number of activities: the provision of information (informational support), hands-on services (instrumental support), emotive sharing of experiences (emotional support), and offering approval to each other (appraisal support). Within social interaction theory is the necessity for a structure where the interactive process can occur, which is the structural social support. Structural social support consists of a set of people or persons in the individual’s social connections, sometimes referred to as social networks. Therefore, the structural Figure 6.1  Conceptual framework showing functional social support expressed as four dimensions: informational, instrumental, emotional, and appraisal support. For the purpose of statistical analysis, a combined score was used to test the hypotheses. Structural social support is tested from two perspectives: formal (health care professionals) and informal (family, friends, and significant others) social support. Postnatal depression and maternal parental self-efficacy are also described. Social Support Functional

Structural

- Informational - Instrumental - Emotional - Appraisal

- Formal - Informal

Postpartum Depression A psychosocial phenomenon occuring within a 12-month period after childbirth

Maternal Parental Self- Efficacy - Care taking procedures - Evoking behaviors - Reading behaviors - Situational beliefs

Source: Leahy-Warren et al. (2011).



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elements of social support are the social networks that can be either formal (health care professionals) or informal (family or friends). The functional elements of social support refer to the exchange activities (i.e., informational, instrumental, emotional, and appraisal support) (Figure 6.1). Maternal parental self-efficacy is the second concept represented in the conceptual framework. The concept of self-efficacy was first written about by Bandura and has been discussed both as one of the major components of social cognitive theory and as a theory in its own right (Bandura, 1977a, 1977b, 1986). Bandura’s work concentrates on perceived self-efficacy, which he describes as a belief in one’s capabilities to organize and execute the course of action required to attain a goal or perform a certain task. Bandura (1986) also distinguishes between outcome expectancy (i.e., how the world works) and self-efficacy (belief and capability of doing). He reasoned that individuals may believe that their own behavior could result in a certain desired outcome but might feel incapable of performing the behavior. In the context of first-time parenting, mothers may feel that they can be a parent, but might feel incapable of performing the behaviors necessary, such as bathing a baby. Bandura (1997) further reinforces the idea that the concept of self-efficacy should be applied to coordinated behavioral sequences rather than subskills. Because parenting involves a number of coordinated behavioral sequences, efficacy in parenting or parental self-efficacy is a necessary component for successful parenting. Maternal parental self-efficacy is mothers’ beliefs in their abilities to organize and execute a set of tasks related to parenting a child, and is an important consideration for new mothers in the postnatal period (Bandura, 1997; Barnes & Adamson-Macedo, 2007; Reece, 1993). The dimensions of maternal parental self-efficacy as delineated by Barnes and Adamson-Macedo (2007) are caretaking procedures (mothers’ perceptions of ability to perform infant care tasks); evoking behaviors (perceptions of mothers’ ability to elicit a change in baby’s behavior (e.g., soothe a crying infant); reading behaviors (perceptions in mothers’ ability to identify changes in infant’s behavior (e.g., when baby is sick); and situational beliefs (mothers’ beliefs about ability to judge their overall interaction with infant). The third major concept is postpartum depression, which is a psychosocial phenomenon occurring within a 12-month period after childbirth (Cooper & Murray, 1998; Goodman, 2004; Kumar, Robson, & Brough, 1984; O’Hara & Swain, 1996). There are a number of theoretical perspectives on postpartum depression. The medical model portrays postnatal depression as a disease with clearly defined symptoms relating to depressed mood after childbirth (American Psychiatric Association, 2000; Whiffen & Johnson, 1998; World Health Organization, 1992). Whiffen and Johnson (1998) suggest that postnatal depression is linked to women’s negative perceptions of their marriages and to perceived lack of support from their spouses, which they explain in the context of attachment theory. Attachment theory, as proposed by Whiffen and Johnson, concentrates on depression and suggests that lack of social support from a spouse or romantic partner is depressogenic (p. 480). Use of attachment theory as a framework for treatment for postnatal depression is limited to women with an emotional partner. In this study (Leahy-Warren, McCarthy, & Corcoran, 2011, 2012), the context of the postnatal period as a time of transition for women in relation to self, role, and position within community is considered, with an emphasis on relationships within their social networks, as demonstrated in Figure 6.1 in the conceptual framework. The social science and feminist perspectives of postnatal depression view mothers as psychosocial beings. Becoming a mother occurs in a number of coexisting environments, such as

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social, economic, and medical. Therefore, first-time mothers’ reactions to first-time motherhood are influenced by all these factors (Beck, 1992, 1993; Mauthner, 1999). Postnatal depression is characterized by at least a 2-week period of clinical symptoms of depressed mood, loss of interest, loss of enjoyment (Beck, 1992, 1993; Chan & Levy, 2004; Ugarriza, 2002), and increased fatigability plus at least two other physical symptoms, such as less energy, less appetite, pessimism, low self-esteem, sleep disturbance, ideas of guilt, and suicidal thoughts (Nicolson, 1990; Scrandis, 2005). The conceptual framework demonstrates the three major concepts and identifies their relationships. The criterion of empirical adequacy for middle range theories is met when instruments have been developed to observe the theory concepts. Finfgeld-Connett (2005) argues that instruments used to measure social support should demonstrate sensitivity within specific contexts. There are several research instruments available that measure social support (Brandt & Weinert, 1981; Logsdon, 1996; Logsdon, Usui, Birkimer, & McBride, 1996; Norbeck et al., 1981). However, following an extensive search and review of the literature, a psychometrically sound, theoretically based instrument measuring social support in the context of infant care practices in the postnatal period was not identified. Therefore, an instrument was designed and developed directly from a large body of literature and utilized the above conceptual framework based on Homans’s (1961) and Blau’s (1964) social exchange theory (Figure 6.1). This instrument, the Perinatal Infant Care Social Support (PICSS) Scale, was used in the study that examined social support for first-time mothers over a period of 3 months postpartum (Leahy-Warren et al., 2011, 2012).

RECOMMENDATIONS FOR FURTHER RESEARCH Advancing scientific knowledge for nursing—particularly maternal and infant health nursing—is crucial to the health and well-being of both mothers and infants. Social support is sought as a facilitator to women’s transition to motherhood and is reported to be significantly associated with maternal role development. However, a lack of consensus on the conceptualization and definition of social support and diversity in instruments used to measure social support has given rise to ambiguity. These factors have contributed to difficulty when making direct comparisons among studies’ findings. To advance scientific knowledge in this area, it is imperative that further research is undertaken that utilizes psychometrically sound, theoretical-based instruments to ensure that evidence-based social support interventions are developed and evaluated to positively contribute to the health and well-being of mothers and infants. The content of the intervention needs to be explicit in terms of the structural and functional components. In this way, consistency of interventions in addition to standardization of outcomes may aid synthesis, generalizability, and transferability of evidence.

SUMMARY The purpose of this chapter is to present an analysis and evaluation of the Social Support Theory, based on publications on the theory’s development. Fawcett and colleagues’ (2001) framework for the analysis and evaluation of theories of nursing allows for both a comprehensive and systematic assessment of Social Support Theory. The criteria identified by Fawcett et al. (2001) for choosing a theory to guide a research



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study have been applied. This analysis demonstrates that Social Support ­Theory ­provides a comprehensive guide toward understanding the m ­ ultidimensionality of social support in the context of infant care practices in the postnatal period. Social support includes structural (formal and informal) and functional (informational, instrumental, emotional, and appraisal) dimensions. It is imperative that future research on social support in the perinatal period is theoretically sound, to ensure that interventions contribute positively to health care outcomes.

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chapter 7

The Health Action Process Approach Theory Elaine Lehane

The Health Action Process Approach (HAPA) is a psychological theory of health behavior change first published in 1992 by health psychologist Ralf Schwarzer. Developed throughout the 1980s, Schwarzer wanted his theory to account for the “intention-behavior” gap. The most popular health behavior change theories of the time—the Theory of Reasoned Action, Protection Motivation Theory, and the Theory of Planned Behavior—predominantly focused on predicting behavioral change intentions rather than actual behavior variance (Schwarzer et al., 2008). Schwarzer addressed this deficiency by developing the HAPA, which explains why people do not always behave in accordance with their intentions, a common occurrence in the field of health care.

BASIC DESCRIPTION OF the THEORY The HAPA facilitates an understanding of health behavior change both in terms of predictors of behavioral intentions and the mechanisms or strategies that translate such intentions into actual behavior. It is an integrated synthesis of social-cognitive theory (Bandura, 1986), the Theory of Reasoned Action (Fishbein & Ajzen, 1975), and the volition theories of Heckhausen, Gollwitzer, and Kuhl (Heckhausen, 1991; Heckhausen & Gollwitzer, 1987; Kuhl, 1983, 1985, 1987) as applied to health behavior (Schwarzer et al., 2008). The HAPA explicitly considers both motivational and volitional processes by outlining the mechanisms that operate when individuals become motivated to change their behavior, when they adopt and maintain a new behavior, and when they attempt to resist temptations and recover from setbacks (Luszczynska & Schwarzer, 2003; Schwarzer, 1992).

CORE CONCEPTS The motivational phase in the HAPA is characterized by the concepts of growing risk awareness, outcome expectancies, and action self-efficacy that lead to the formation of a behavioral intention (Figure 7.1). Risk perception involves the evaluation of an

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Part II  Theories Applied to Research Figure 7.1  Health Action Process Approach (HAPA) Model. Action Self-Efficacy

Outcome Expectancies

Maintenance Self-Efficacy

Intention

Action Planning Coping Planning

Recovery Self-Efficacy

Initiative

Maintenance

Recovery

Risk Perception Motivationl Phase

Action Volitional Phase

Reprinted with permission from Schwarzer (2008). Copyright © R. Schwarzer 2008. All rights reserved.

event in which harm is anticipated and a response is elicited. Schwarzer (2008a) perceives it as a distal antecedent of intention formation because by itself it is insufficient to enable a person to form an intention. Outcome expectancies (i.e., an individual’s expectations of the effectiveness of a recommended health behavior) (Schwarzer, 1992) and action self-efficacy, defined as the belief in one’s capabilities of initiating and performing a course of action for a desired outcome (Bandura, 1997; Schwarzer, 2008a), are seen as the substantial contributors to the formation of strong behavioral intentions within the motivation stage of the HAPA. Once the intention has been formed, it must be translated into the desired behavior. According to the HAPA, this is achieved through two major concepts: strategic planning and volitional self-efficacy. Planning is a prospective self-regulatory strategy that has been defined in social cognition literature as “the mental stimulation of behavior in order to be prepared for situations in which the behavior should be performed” (Lachman & Burack, 1993, p. 131). Planning predominantly serves two functions and is therefore usually subdivided into two dimensions (as it is in the HAPA), that of action planning and coping planning (Araujo-Soares, McIntyre, & Sniehotta, 2009) (Figure 7.1). Action planning specifies the when, where, and how of implementing an intended behavior. Action planning gives individuals alternative responses and activates cognitive processes that utilize situational cues for the intended behavior (Gollwitzer, 1999). Such plans essentially link a specific behavior to specific cues within a specified time and spatial frame, and take the form “I intend to do X, at time Y, in place Z.” The predominate function of action planning is to delegate control of the action to the environment, whereby the behavior becomes linked to the environmental cue that eventually leads to the automatic elicitation of the behavior when the cue is encountered (Gollwitzer, 1993; Jackson et al., 2005). Coping planning is a barrier focused self-regulation strategy and refers to an individual anticipating difficulties or barriers that might hinder the implementation of a specific behavior (Scholz, Sniehotta, Burkert, & Schwarzer, 2007). It is contended that people who plan on how to cope with risk situations are more likely to maintain a newly adopted behavior in face of difficulties (Gollwitzer & Sheeran, 2006; Scholz, Schüz, Ziegelmann, Lippke, & Schwarzer, 2008; Sniehotta, Scholz, & Schwarzer, 2006). The volitional processes involved in such planning can be influenced by perceived situational barriers, resources, and support (Schwarzer et al., 2007).



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Self-efficacy also plays an important role in the volitional phase of the HAPA. Volitional self-efficacy is subdivided into maintenance and recovery self-efficacy (Figure 7.1). Maintenance self-efficacy represents individuals’ optimistic beliefs about their ability to cope with barriers that may arise during the maintenance of a new behavior (Schwarzer, 2008a). Recovery self-efficacy refers to a person’s capability and conviction to regain control of a behavior if a lapse in that behavior has occurred (Schwarzer, 2008a). Within the HAPA, self-efficacy is functional at different levels and at different time points throughout intention formation and behavioral enactment. For example, it is suggested that some people are more confident in their ability to set goals (action self-efficacy) and to take initiative but have little confidence in their ability to maintain a desired behavior (volitional [maintenance] self-efficacy). In contrast, some people may be confident in their ability to recover from setbacks or failures in carrying out desired actions (volitional [recovery] self-efficacy) but possess little confidence in initiating the necessary behavior (action self-efficacy) (Luszczynska & Schwarzer, 2003). The HAPA can be categorized as both a continuum and stage model of behavior change (Abraham, 2008; Leventhal & Mora, 2008; Sutton, 2008; Velicer & Prochaska, 2008). Schwarzer states that the HAPA constitutes a hybrid model in that researchers can apply it either as one or the other, depending on the research question posed (Schwarzer, 2008c). Continuum models assume that levels of core social cognitive variables are linearly related to the likelihood of performing a desired behavior (Sniehotta, 2007). Therefore, the continuum version of the HAPA serves to explore the mechanisms and mediating processes (e.g., planning and self-efficacy) of behavior change (Schwarzer, 2008b). Stage models assume that behavior change passes through an ordered sequence of different stages characterized by similar barriers for stage progress and different barriers for different stages (Sniehotta, 2007). For example, a three-stage model (preintenders, intenders, and actors) reflects a stage view of the HAPA with each stage having its own set of processes that are required to progress a behavior within the change process (Lippke, Ziegelmann, & Schwarzer, 2005). The stage version of the HAPA can therefore serve to investigate targeted interventions within controlled trials (Schwarzer, 2008c). The HAPA focuses on processes through which individuals form behavioral intentions and translate such intentions into actual, sustained behavior. It does not focus on imprecisely articulated personal characteristics to explain behavior change, and can be considered a versatile theoretical framework that allows researchers to access its key concepts and assumptions for use in a variety of situations (Schwarzer, 2008c). In light of these attributes, the HAPA can be seen as a particularly pragmatic means of assisting clinicians in practically translating health behavior change strategies into effective clinical applications (Maes & Karoly, 2005).

RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS THEORY The majority of research studies relating to the HAPA have been conducted by social, behavioral, educational, and health psychologists. In particular, a large group of researchers at the University of Berlin, Germany, have devoted a proportion of their research agenda to investigating the utility of the HAPA in understanding and promoting health behavior change. Studies conducted to date have examined different health behaviors, using diverse samples, various measures, and different time spans. Examples of these behaviors include sunscreen use (Cranciun, Schüz,

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Lippke,  & Schwarzer, 2012); physical activity (Chiu, Lynch, Chan, & Berven, 2011; Koring et  al., 2012; Luszczynska, Sarkar, & Knoll, 2007; Scholz et al., 2008; Scholz, Sniehotta, & Schwarzer, 2005; Sniehotta et al., 2005); fruit consumption (Kreausukon, ­Gellert, Lippke, & Schwarzer, 2012; Luszczynska, Tryburcy, & Schwarzer, 2007); dietary intake (Renner et al., 2008; Reuter, Ziegelmann, Wiedemann, & Lippke, 2008); oral hygiene (Schüz, Sniehotta, Mallach, Wiedemann, & Schwarzer, 2009; Schüz, Sniehotta, & Schwarzer, 2007); physical rehabilitation (Schwarzer, Luszczynska, Ziegelmann, Scholz, & Lippke, 2008); seat-belt use (Schwarzer et al., 2007); and breast self-examination (BSE) (Luszczynska & Schwarzer, 2003). These studies have been predominantly designed to examine the causal structure of the HAPA in relation to the aforementioned behaviors. Although research conducted to date has been mainly confined to single-study investigations rather than research synthesis procedures, the evidence derived has been useful in examining the validity of the model. This section presents a brief appraisal of a selection of such studies. Luszczynska and Schwarzer (2003) conducted a longitudinal study over 15 weeks to examine the fittingness of the HAPA in explaining the performance of BSE. The researchers examined whether the explanatory power of the three motivational concepts of risk perception, outcome expectancies, and self-efficacy in predicting BSE was augmented by the addition of the volitional self-regulatory concepts of planning and volitional self-efficacy. Women college students (N = 418) participated and completed a questionnaire (based on the concepts) at time point 1. Once completed, participants were given information on how to perform a BSE and any questions relating to this topic were subsequently answered by researchers. Time point 2 data were collected 12 weeks to 15 weeks later. Data analysis via structural equation modeling indicated that the hypothesized model fitted the data well with all of the components of the HAPA, excluding risk perception, operating in line within the context of BSE behavior. In particular, self-efficacy (task) and planning emerged as the best concepts in predicting intentions and BSE behaviors, respectively. Evidence supporting the explanatory utility of differentiating between task and volitional self-efficacy also emerged. Whereas the findings within this study are based on theory and time lag as opposed to experimental manipulation and can therefore be critiqued in terms of possibly being derived from method effects (e.g., the study heightened women’s awareness of BSE issues and the need to perform BSE), tentative support for the combination of motivational and volitional phases as a useful heuristic for behavior enactment was evident. Schwarzer and colleagues conducted three longitudinal studies in 2008 (Schwarzer et al., 2008), the aim of which was to examine the validity of the HAPA Model for explaining physical exercise adherence in patients undergoing rehabilitation. A prediction model was examined in each study with participants who were enrolled in cardiac rehabilitation (study 1, N = 353; study 2, N = 114) or orthopedic rehabilitation (study 3, N = 368). The model specified three predictors of the intention to exercise (action self-efficacy, outcome expectancies, and risk perception) and three predictors of the behavior (intention, planning, and recovery self-efficacy). Two main research questions were posed: (1) Does a structural equation model, specified in terms of the HAPA, fit the data in all three studies? (2) Do the two volitional concepts of planning and recovery self-efficacy account for variance in self-reported physical exercise? Each study included three measurement time points, covering a period of 4 months and 12 months. For study 1, participants enrolled in a 3-week inpatient cardiac rehabilitation program in Germany were assessed at weeks 2, 8,



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and 16. In study 2, participants being treated for an MI (myocardial infarction)—and subsequently attending a cardiac rehabilitation program in Poland—were assessed at 4 days to 10 days post-MI, at week 8 post-short-term rehabilitation, and at 8 months. Study 3 used a cohort of participants attending orthopedic rehabilitation in Germany with assessment time points at week 1, when rehabilitation commenced, and 6 months and 12 months postdischarge from rehabilitation. Physical activity, risk perception, positive outcome expectancies, action self-efficacy, and behavioral intentions were assessed at time point 1. Planning and recovery self-efficacy were assessed at time point 2, with physical activity assessed again at the final time point. All psychometric scales were adapted from Sniehotta et al. (2005) and Scholz et al. (2005), with the exception of the International Physical Activity Questionnaire that was developed by Booth (2000). For all studies, path analysis with maximum likelihood estimation was used to examine the longitudinal association among the HAPA variables. Evaluation of model-data fit was based on the Tucker-Lewis index (TLI), comparative fit index (CFI), root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR), and times 2 divided by degrees of freedom (× 2/df). Standard values of goodness of fit were adopted. Findings from all three studies indicated that the HAPA Model fit the data, although not optimally in the third study where the hypothesized paths of risk perception and outcome expectancies were not significant. Planning and recovery self-efficacy, as hypothesized, accounted for a significant amount of variance for adhering to physical exercise in each study. The studies’ methodological limitations were confined to the self-report nature of the behavior under investigation and by weak psychometric properties of some of the assessment measures used. Despite this, it must be acknowledged that the findings supported the validity of the model for explaining physical exercise adherence among patients undergoing rehabilitation—in three different patient populations, in two different cultures, and across various time spans. More recent studies by Cranciun et al. (2012) and Teng and Mak (2011) further support the applicability of the model to different health-enhancing behaviors. Cranciun et al. (2012) used the HAPA as a theoretical framework to explore the selfregulatory mechanisms of sunscreen use. An international (Romanian, English, Portuguese, and Spanish) longitudinal Internet-based survey was conducted with 524 individuals, predominantly university students. Intentions, positive outcome expectancies, distal self-efficacy, and risk perception were assessed at time point 1, when participants received the survey via e-mail after consent was gained. Intention, planning, and proximal self-efficacy were measured 2 weeks later, with sunscreen use reported at the 3-month follow-up time point. A longitudinal structural equation model with multiple indicators was examined, with the data analysis findings attesting to the applicability of the HAPA in the context of sunscreen use. Specifically, positive outcome expectancies, self-efficacy, and, to a lesser extent, risk perception predicted behavioral intentions, with planning and volitional self-efficacy predicting actual sunscreen use. Teng and Mak (2011) applied the HAPA to investigate the motivational and behavioral patterns of men who have sex with men (MSM) in condom use. It was proposed that risk perception, outcome expectancy, and action self-efficacy would predict condom use intention and that planning and phase-specific self-efficacies would facilitate behavior change resulting in condom use. Participants (N = 217) were recruited by MSM peer recruiters from local gay venues, and they completed the questionnaire at time point 1 (on consent) and time point 2 (1 month later). All HAPA variables were

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measured at time point 1, and sexual behaviors were measured at both time points. A battery of instruments with satisfactory psychometric properties were used to measure the various concepts: Schwarzer’s (2008a) generic HAPA Model measures; the Costs and Benefits for Condom Use survey (White, Terry, & Hogg, 1994); the Condom Use Self-Efficacy Scale (CUSES) (Brien, Thombs, Mahoney, & Wallnau, 1994); and the Socially Desirable Response Set Survey (SDRS-5) (Hays, Hayashi, & ­Stewart, 1989). The findings demonstrated that the HAPA Model had a good overall fit to the data, with condom use predicted by planning, maintenance self-efficacy, and intention, which were in turn predicted by action self-efficacy, outcome expectancy, and risk perception. Planning in particular appeared to be the most important predictor of behavior, a finding that is in keeping with previous study results (Schwarzer et al., 2007). Again, the overall model fit the data well, replicating the model previously established in other health behaviors (Luszczynska, 2006; Payaprom, Bennett, ­Alabaster, & ­Tantipong, 2011; Schwarzer et al., 2008; Sniehotta et al., 2006). Although the findings from both studies attest to the applicability of the model, they do not necessarily prove that the model chosen is the only one that fits. A more pertinent question to be answered is whether the HAPA is superior to alternative models, in terms of the amount of behavioral variance explained. Comparative experimental studies among different models of behavior change are therefore needed to further test the validity of the model (Cranciun et al., 2012). The aforementioned studies have investigated the utility of the model in its entirety in terms of its predictive ability in relation to health behavior change. In general, support for the universality and applicability of the model across different health behaviors, samples, and cultures is apparent, although higher levels of evidence via research synthesis and trial designs are needed to strengthen whole model validation. Additional investigations have also been conducted that have focused on specific HAPA postintentional concepts, especially volitional self-efficacy and planning (Gutiérrez-Dona, Lippke, Renner, Kwon, & Schwarzer, 2009; Koring et al., 2012; Kreausukon et al., 2012; Luszczynska et al., 2007b; Reuter et al., 2009; R ­ ichert et al., 2010). Methodologies used in these studies have extended to experimental manipulation (Lippke, Ziegelmann, & Schwarzer, 2004; Scholz, Knoll, Sniehotta, & Schwarzer, 2006; Sniehotta et al., 2006; Ziegelmann, Lippke, & Schwarzer, 2006) and systematic review/meta-analyses (Gollwitzer & Sheeran, 2006). The stage layer of the model has also been examined (Lippke et al., 2005; Luszczynska, Goc, Scholz, Kowalska, & Knoll, 2011; Renner & Schwarzer, 2005; Schüz et al., 2009; Wiedemann et al., 2009;). Overall, this body of evidence also lends support for the HAPA concepts and theoretical relationships. Compared to more established health behavior change theories such as the Health Belief Model and Theory of Planned Behavior, researchers are increasingly turning their attention toward the HAPA to provide a more direct prediction of actual behavior and guide patient-tailored health change interventions.

RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS Given that the HAPA is a psychological theory of health behavior change, the nursing metaparadigmatic concepts are not directly addressed. Nevertheless, how the model relates to the metaparadigm concepts can be deduced by Schwarzer’s writings and associated publications. Because the HAPA is an integrated synthesis of social



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cognition and self-regulatory/volitional theories of health behavior, the following statements are based on an amalgamation of these theories’ major assumptions. The person is seen as an active agent in personal decision making who makes systematic use of available information. Individuals consider the implications of their actions before deciding to engage in a particular behavior, and patients interpret events that affect them on a rational but subjective basis that is unique to them. Changes in behavior do not always happen from knowing information in isolation. Decisions and subsequent actions are influenced by feelings and emotional responses. Self-belief in striving toward health goals is essential in attaining and persevering with such goals. Environment can refer to any factor that can impact upon behavior. There are social (e.g., family/friends) and physical (e.g., situational cues) environments. Individuals are part of a social world, and patients must be viewed in the context of others and their broader social world. Cognition formation is shaped through socialization processes, with health behavior decisions and actions being influenced by environmental barriers or facilitators (Conner & Norman, 1996; Horne, Parham, Driscoll, & Robinson, 2009; Ogden, 2007). The metaparadigmatic concepts of health and nursing are not explicitly defined or discussed. However, because the HAPA is a theory of health behavior change, it is implicit that health is a state of being to be valued. Health-enhancing behaviors should be sought and maintained through motivational, volitional, and actional processes that are, in principle, under an individual’s control. Health care professionals must be knowledgeable in the different processes required for sustained behavior change, and use this expertise to guide patients in selecting the most appropriate intervention to meet their specific needs in reaching and maintaining their desired health goals (Schwarzer, 2008b).

THEORY ANALYSIS The HAPA is evaluated according to Fawcett’s (1999, 2005) and Bredow’s (2004) criteria of significance, internal consistency, parsimony, testability, empirical adequacy, and pragmatic adequacy. Specific relevant questions from Fawcett’s (1999, 2005) appraisal framework as applied to the author’s study are also examined in Table 7.1. The HAPA is concerned with describing, understanding, and predicting health behavior change, particularly within the realm of promoting health-enhancing behaviors. It can therefore be considered as dealing with a topic that society and nursing regard as practically important. In addition, the HAPA offers new and compelling insights into this topic over and above those of other health behavior change theories, by virtue of the fact that it explicitly considers both motivational and volitional processes associated with behavior change. Traditional change theories predominantly only focused on the motivational dimension. The HAPA Model possesses semantic clarity as well as semantic and structural consistency. All of the model’s concepts have been theoretically and operationally defined in a consistent manner since its inception. Structural clarity is evident due to the logical and intuitive organization of the model as a whole, which make the conceptual interrelationships relatively easy to understand. The seminal chapter explicating the HAPA uses academic but comprehensible language, and subsequent publications have used relatable examples of the concepts that further enhance the model’s clarity.

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Table 7.1 Evaluative Criteria as Applied to the Health Action Process Approach (HAPA) Theory Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

Yes, the HAPA facilitates an understanding of health behavior both in terms of the motivational predictors of behavioral intentions and the volitional strategies that translate such intentions into behavior. Thus, it fits the research study conducted that aimed to elucidate the cognitive-motivational and volitional self-regulatory factors that influence medication adherence for the purpose of developing a medication adherence measurement instrument.

2.

Is it readily operationalized?

Yes, Schwarzer (2008a) provides clear theoretical and operational definitions that are consistent throughout the model, are presented in a parsimonious way, and are congruent with the model’s key principles.

3.

How well has the theory performed at describing, predicting, and/or explaining phenomena to which it relates?

Support for the HAPA’s utility and universality in predicting health behavior and affecting change is evident through various studies that have used the model for its explanatory power in understanding the motivational and self-regulatory mechanisms of a number of behaviors including physical exercise, sunscreen use, breast self-examination (BSE), dietary intake, and physical rehabilitation. More recently, the model has also been used in studies to guide the development of health-promoting interventions, with promising effects (Milnes, McGowan, Campbell, & Callery, 2013; Payaprom, Bennett, Alabaster, & Tantipong, 2011).

4.

Does the theory relate to and address the research aim and objectives in its description and explanation?

Yes, the model relates to and addresses the research aim and objectives in its description and explanation of the motivational and volitional processes as applied to medication adherence behavior in patients diagnosed with coronary artery disease (CAD). This in turn informs the process of developing and psychometrically testing a medication-specific adherence measurement instrument.

5.

Does the theory flow from the research aim?

The study aim has the potential to progress knowledge of patient medication adherence for a long-term condition and in turn exact behavior change, in terms of identifying, via a measurement instrument, specific motivational and/or volitional processes that may hinder adherent behavior. The HAPA therefore guides the development of the study aim and objectives.

6.

Are the assumptions congruent with the assumptions that are made for research?

Yes, the key assumption is congruent in that both intentional (motivational) and unintentional (volitional) dimensions of medication adherence must both be considered if adherent behavior is to be successfully achieved.

7.

Is the theory oriented to outcomes that are critical to patients?

Yes, the HAPA seeks to determine the mechanisms that facilitate the accomplishment of health-enhancing behaviors such as adhering to therapeutic medication regimens, an outcome that can be considered critical to patients’ well-being.

8.

Are tools available to test relationships of the theory or do they need to be developed?

For this study, the primary outcome of the research was the development of a medication-specific adherence measurement instrument for use with patients on pharmacotherapy for the treatment of CAD. Examples of items that may be used to develop tools for use with specific health behaviors are provided by Schwarzer (2008a).

Source: Fawcett (1999, 2005).



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Schwarzer achieves the criterion of parsimony in his description and explication of the HAPA. Whereas the process of behavior change can be considered complex, Schwarzer has used the fewest concepts possible to explain this phenomenon. This is particularly apparent in the motivational phase of the model that only uses three key concepts to describe how a behavioral intention may be formed. Although complexity is evident in the volitional phase in terms of the subconcepts associated with self-efficacy, the relationships and concept linkages are concisely and clearly stated. Overall, the HAPA organizes a rather complex phenomenon into an easily understood and useful form. Testability refers to “the extent to which the theory can be tested empirically” (Fawcett & Garity, 2009, p. 52). Each concept of the HAPA Model can be empirically measured, albeit predominantly indirectly through research instruments. Schwarzer (2008a) provides examples of items that may be used to develop measures to represent each of the model concepts. In using the HAPA to guide empirical investigations, researchers have both developed instruments based on Schwarzer’s guiding exemplars (Sniehotta et al., 2005) and have used previously established and validated instruments (Teng & Mak 2011). In addition, data analysis techniques, mainly structural equation modeling, have facilitated the testing of the model’s predictive pathways. The extent to which the HAPA has achieved the criterion of empirical adequacy is debatable. The majority of studies conducted to date have supported the assertions made by the model. However, this evidence derives from the findings of single studies that used similar methodologies and data analysis techniques. Further definitive evidence is needed—through data synthesis procedures and through more varied methodologies, particularly in the area of intervention and comparison studies with alternative theories of health behavior change—to establish its empirical adequacy. Evidence of the model’s pragmatic adequacy is limited, due to the small number of studies that have been conducted in relation to nursing practice (Milnes, McGowan, Campbell, & Callery, 2013; Payaprom et al., 2011). Nevertheless, it is apparent from these studies and the model’s key assumptions that the HAPA can inform clinical practice in a socially meaningful way, particularly within the encompassing context of health promotion. To date, the model has been used to guide the development of an assessment tool (Lehane, McCarthy, Collander, Deasy, & O’Sullivan, 2013), an interventional protocol (Payaprom et al., 2011), and practice guidelines (Milnes et al., 2013) that are useful and valuable to nursing. The model’s focus on promoting health-enhancing behavior points toward its significant potential for securing favorable clinical outcomes for patients. Additional nursing research is required to lend credence to the usefulness of the HAPA Model for professional practice.

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING Few studies are evident within the literature using the HAPA as a theoretical framework for guiding research investigations into nursing issues. This may be due to the fact that the HAPA is relatively new compared to more established health behavior change models; therefore, uncertainty regarding its validity may have been an issue. Given the increased number of studies and researchers using the HAPA in recent years, however, a body of evidence has grown that tentatively suggests the model is useful for predicting actual behavior change, particularly in healthpromoting activities. In addition, the stage element of the model is seen as useful for

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tailoring interventions for specific patient needs, a characteristic that traditional social cognitive behavior models fail to take into consideration. Because health promotion and the prevention of health-compromising behaviors are fundamental to nursing practice, the HAPA is eminently appropriate for guiding nursing research investigations. Two recent nursing studies in the area of health promotion used the HAPA to guide the development of study interventions: an influenza vaccination information leaflet (Payaprom et al., 2011) and a preconsultation guide for young people who attend practice nurses for asthma management reviews (Milnes et al., 2013). Payaprom et al. (2011) conducted an investigation among high-risk Thai individuals regarding whether a leaflet addressing HAPA variables and incorporating an action planning intervention would result in higher intentions to seek influenza vaccination and higher vaccination rates than a standard government leaflet. Using a controlled before-and-after trial design, participants were randomly chosen from pools of eligible participants in two geographically separate communities in Thailand. The intervention group (N = 99) received a HAPA-based leaflet that used behavior change techniques including providing information about the behavior– health link; increasing efficacy in relation to participants’ ability to cope with the vaccination schedule by including personal accounts of people who had received the vaccination; and asking them to develop detailed plans of where, when, and how they would obtain the vaccination. The comparison group (N = 102) received the standard government information leaflet that provided information about flu symptoms, details about the vaccine, possible side effects of the vaccination, and general vaccine benefits. Two sets of outcome measures were used: (a) process measures of HAPA-related variables taken at time points 1 (baseline) and 2 (2 weeks after receiving the leaflets), and (b) vaccination rates for the subsequent 2 months. Examination of the relationships between the hypothesized predictor and outcome measures were first analyzed by Pearson’s correlational test and subsequently by linear and logistic regressions. The findings demonstrated that, overall, the HAPA intervention resulted in greater and statistically significant (p < .001) changes regarding risk perception, outcome expectancy, self-efficacy, and intention scores than in the comparison group. In addition, planning specifically was shown to be associated with notably greater changes over time on all variables. However, no statistically significant difference in vaccination rates was observed between the two groups and, interestingly, action planning did not contribute to the prediction of vaccine uptake. Two key confounding factors would have impacted upon these results, however. During the trial period there was a global outbreak of H1N1 influenza, causing an unprecedented high uptake of vaccinations. Achieving significant differences between the two groups would have been difficult. Nevertheless, a 5% difference was found in vaccination rates between groups. Second, the study was underpowered to detect the small differences in vaccination rates that were found. Despite the lack of statistical evidence relating to vaccination uptake rates, the HAPA intervention demonstrated behavioral intention change, further adding to the body of evidence in relation to the utility and applicability of the HAPA to promote health-enhancing behaviors. Milnes et al. (2013) applied the concepts of the HAPA to the development of criteria underpinning a preconsultation guide for use with young people prior to an asthma review with their practice nurse. The purpose of such reviews is to develop individualized education programs and self-management plans by negotiating patient-identified goals. The article described the theory and modeling phases in



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the development of the guide that would require assessment for feasibility, acceptability, and effectiveness in a subsequent study, as recommended by the Medical Research Council (MRC) framework for the development and evaluation of complex interventions in health care settings (Craig et al., 2008). For the mapping of the theory stage, a literature review was conducted to explore and consider theoretical and evidence-based components and processes of the behavior under investigation. Key findings from the review indicated the need for the guide to facilitate young people’s identification and communication of health concerns; promote relationship building; promote information giving by question asking; and provide reassurance and confidence. Based on these findings, the HAPA was identified as the most suitable health behavior change model to underpin the guide—namely, because of its emphasis on self-efficacy across both motivational and volitional stages of behavior change. Self-efficacy is an especially important concept to consider with this patient cohort because they deal with behavior change barriers such as lack of confidence, not knowing how to ask questions, and not being able to communicate concerns. For the modeling stage, the ingredients of the preconsultation guide, the contextual influences, and the interactions between them were identified using a panel of 11 experts in asthma management and a nominal group technique with 8 young people ages 13 years to 18 years. The results from the nominal group suggested that the HAPA concepts underpinning the guide were both appropriate and relevant. The guide is the first step in the development of an intervention that could have the potential to improve nurse/patient consultations. Although the HAPA is not a theory of nursing, it is nonetheless a theory of a phenomenon that concerns nursing; it holds significant promise for guiding nursing research, particularly in the area of complex interventions. In recent years, there have been increasing calls for nursing research to turn its attention toward designs that have the potential to improve the quality and explanatory power of nursing science and practice, to ensure that nursing realizes its potential for a secure evidencebased contribution to clinical patient outcomes and the wider health care agenda (­Richards & Borglin, 2011). This would require a shift away from a nursing research tradition that is predominantly descriptive, cross-sectional, and context-specific to one that is translational, experimental, longitudinal, and implementation-focused (Hallberg, 2009). A fundamental principle of the HAPA emphasizes the importance of volitional concepts to change and maintain actual behavior. Specific theoretically guided interventions can therefore be developed to achieve a desired behavioral outcome. Second, the HAPA highlights the differences that exist in people in terms of their readiness to change behavior, a consideration that is essential to take into account when tailoring interventions. The HAPA would provide nursing researchers with the theoretical underpinning and practical guidance needed to conduct such complex intervention research.

USE OF THE THEORY IN THIS RESEARCH The Reasoning and Regulating Medication Adherence Instrument was developed to measure the factors that influence adherence to medications in patients prescribed pharmacotherapy for the treatment of coronary artery disease (CAD). To facilitate the collection of credible data from a health measure, it is recommended that instrument development proceed from theory (DeVellis, 2012; Streiner & Norman, 2008;

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Part II  Theories Applied to Research Figure 7.2  Diagrammatic representation of medication adherence theoretical framework. Risk Appraisal Severity Vulnerability

CognitiveMotivational Processes

Outcome Expectancies Physical Social Emotional Self-Efficacy Task (action) Volitional

Volitional Self-Regulatory Proccsses

Medication Adherent Behavior

Planning Strategies Action Planning Habit Strength Maintenance Planning Medication Support/Tracking

Waltz, Strickland, & Lenz, 2010). The HAPA guided the development of a neotheoretical framework of medication adherence in terms of elucidating the framework’s underlying philosophical assumptions, concept selection, and theoretical relationships. This in turn facilitated a systematic and unambiguous approach to instrumentitem generation and psychometric testing that subsequently led to a new medication adherence measure and the Reasoning and Regulating Medication Adherence Neotheoretical Model. A description of the initial theoretical framework guiding the research is warranted to illustrate the HAPA’s contribution to its development. Comparable to the HAPA, the key assumption underpinning the framework was that the adoption and maintenance of medication-taking over a prolonged period of time require the consideration of both cognitive-motivational and volitional self-regulatory processes. For the purposes of medication adherence behavior specifically, cognitive-motivational processes were concerned with the intentional dimension of nonadherence, which relates to the decision to adopt the behavior of taking medications or, in other words, form an intention to take medications. The volitional self-regulatory processes concerned with the unintentional dimension of nonadherence relate to the strategies employed by individuals to implement and maintain the actual health behavior. The core concepts of the framework guiding initial instrument development were informed both by the HAPA and an extensive review of medication adherence literature that enabled operationalization and contextualization of the framework concepts to the specific behavior of medication adherence. Risk appraisal, outcome expectancies, self-efficacy, and planning strategies were the key constructs representative of cognitive-motivational and volitional self-regulatory processes, respectively, as illustrated in Figure 7.2. The associated concepts included perceived severity and vulnerability (risk appraisal concept); physical, social, and emotional outcome expectancies (outcome expectancies concept); task (action) and volitional self-efficacy (self-efficacy



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concept); and habit formation, social support, and situational resources (planning strategies concept). A brief description and operationalization of each concept follows.

Risk Appraisal Schwarzer and colleagues (2007) stated that a minimum level of concern must exist for people to contemplate the benefits of possible actions in relation to minimizing a specific threat. For the guiding framework, the definition and operationalization of risk appraisal was further informed by adherence literature that necessitated the specification of the concepts of perceived severity and vulnerability. Perceived severity related to the perceived relevance or seriousness of the health threat to the individual. Perceived vulnerability concerned individuals’ beliefs about their perceptions of being affected by a health threat, and emphasized the affective rather than cognitive dimension of risk perception (Brewer, Chapman, & Gibbons, 2007).

Outcome Expectancies Schwarzer et al. (2007) asserted that an outcome expectancy is the belief that a given action will lead to a defined result, whether beneficial or not. Outcome expectancies were further operationalized along the concepts of physical, social, and emotional outcome expectancies, as recommended by Bandura (2004). Physical outcomes involve the agreeable (e.g., improved ability to exercise, improved quality of life) and aversive effects (e.g., medication side effects) of behavior and the accompanying material losses and benefits. Social outcome expectancies concern the regulation of behavior by positive or negative social reactions or sanctions produced in a patient’s interpersonal relationships (e.g., medical professional censure traditionally associated with nonadherence). Emotional outcome expectancies concern the agreeable or unpleasant feelings associated with behavior and the associated affective dispositions (e.g., fear/dependency).

Self-Efficacy Schwarzer et al. (2007) contended that for behavior that requires long-term performance, two key concepts, task (action) and volitional self-efficacy, should be taken into consideration equally. Accordingly, self-efficacy within this framework was operationalized along these two concepts. Task self-efficacy pertained to a person’s perceived capability to implement certain behavior, whereas volitional self-efficacy concerned individuals’ beliefs about their capability to persist with the behavior in spite of potential barriers or setbacks. With regard to the assessment of medication adherence for patients with a chronic illness: It is important that the individual’s perceived efficacy in performing a specific behavior or task is not only evaluated but that the person’s perceived capability to maintain such a behavior over a prolonged period of time is also considered.

Planning Strategies Volitional self-regulatory processes are concerned with issues surrounding action initiation and maintenance, as well as the strategies that resolve such issues. Effective strategies are required to overcome such difficulties, and the formation of plans is

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one such key strategy that the HAPA emphasizes for successful prolonged behavior change. As defined by one of Schwarzer’s colleagues in their continued refinement of the HAPA, Sniehotta et al. (2005) stated that planning is a prospective self-regulatory strategy, a mental simulation of linking concrete response to future situations. Planning can be further subdivided into action planning and maintenance planning. Action planning links goal-directed responses to situational cues by specifying the action in terms of when, where, and how to act (Sniehotta et al., 2006). Maintenance planning is a barrier-focused, self-regulation strategy that represents a mental link between anticipated risk or distraction situations and suitable planning responses (Sniehotta et al., 2006). In terms of adherence, it is essential that patients not only form ways of consistently taking their medications over a prolonged period of time but that patients also develop effective responses to situations that may compromise adherence to regimes on a continual basis. Action planning in this framework was operationalized along the concept of habit. Current research conceives habit as a cognitive psychological concept that should be measured as such (Verplanken & Orbell, 2003). Habit was therefore operationalized through habit strength, which is characterized by features of behavior repetition and automaticity (i.e., lack of control and awareness, efficiency) (Verplanken & Orbell, 2003). In terms of maintenance planning, consideration was given to situational factors as recommended by Schwarzer et al. (2007) and was therefore operationalized as medication support (e.g., the existence of a spouse who checks whether the medications have been taken) and medication tracking (e.g., situational barriers/resources, disruption to daily activities, limited access to the pharmacy, pillboxes).

Theoretical Relationships Given that the purpose of the research undertaken was the development and testing of an instrument to measure adherent behavior to medications, the framework was regarded as having continuum properties, which assumed that each of the core concepts was linearly related to the behavior of medication adherence. Therefore, the initial guiding framework suggested that medication adherence over a prolonged period of time requires the simultaneous consideration of both cognitive-motivational and volitional self-regulatory processes. The former processes are influenced by the core concepts of risk appraisal, outcome expectancies, and task self-efficacy; the latter

Figure 7.3  Reasoning and Regulating Medication Adherence Neotheoretical Model. Health Risk Medication Reasoning

Health Protection Medication Adherent Behavior

Medication Regulating

Medication Planning Strategies



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processes are represented by the specific planning strategies of habit strength, medication support, and medication tracking. Volitional self-efficacy was also proposed to play a key role in determining the extent to which medication-taking would be maintained over a prolonged period of time. Therefore, according to the medication adherence framework outlined, in order for successful medication adherence, individuals must perceive that they are at risk of harm due to their condition, that beneficial effects can be derived from taking medications, that they are capable of taking and maintaining the medication regimen, and that planning strategies are in place to assist adherent behavior over a prolonged period. From the description provided, it is clear that the HAPA—with its underlying key assumptions, core concepts, and theoretical relationships—informed to a large extent the development of the theoretical framework. This in turn provided conceptual clarity to elucidate the key adherence influencing factors in medication-taking that led to a well-defined measurement process. This process included deliberation on the content of the measure, the generation of specific items to represent each concept, and the operationalization of item grouping and measure scoring. In addition, psychometric testing and interpretation of analysis findings were also informed by the guiding framework, in terms of decisions made in relation to the parameters applied to the factor analyses used. The final factor solution derived, following psychometric testing, offers researchers a new adherence instrument (Lehane et al., 2013) that is underpinned by a theoretically sound, medication-specific, neotheoretical model (Figure 7.3). The neomodel includes the final factors of medication planning strategies, health risk, and health protection. Medication planning strategies, through its seven representative instrument items, confirmed the relevance of the volitional self-regulatory processes of habit strength and medication-tracking strategies in promoting adherence to medications, as outlined in the guiding theoretical framework. In addition, the factor included items pertaining to volitional self-efficacy that supported the importance of such health beliefs in facilitating these volitional planning strategies. Through the factor labeled health risk, and its representative five items, support was provided for the suggestion outlined in the framework that the patients’ appraisal of risk from a health threat needs to be measured from both a cognitive and affective perspective to determine the extent to which such a health belief impacts upon the decision to adhere to a medication regimen. The final factor of health protection, with its representative four items, supported the significance of the physical and emotional dimensions of the outcome expectancy concept that was proposed by the framework to be a key cognitive-motivational process influencing medication adherence. The items retained through the exploratory factor analysis focused on measuring the extent to which medications had a positive impact upon physical health and emotional well-being. The factors of medication planning strategies, health risk, and health protection provide further conceptual clarity on the influential cognitive-motivational and volitional self-regulatory processes that contribute to medication adherence. With the exception of the items representing social outcome expectancies, medication support, and task self-efficacy, the original proposed theoretical framework was supported by the factor analysis results. The Reasoning and Regulating Medication Adherence Neotheoretical Model provides a new and parsimonious interpretation of the cognitive-motivational and volitional self-regulatory processes that influence prolonged adherence to medication regimens.

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RECOMMENDATIONS FOR FURTHER RESEARCH The most significant and strategic recommendation for future research involving the HAPA relates to the further confirmation of the model’s empirical adequacy. The majority of research conducted to date has focused upon accumulating evidence for the validity of the mediator model and investigating the impact of specific moderators. These investigations were necessary and appropriate to build support for the applicability and universality of the HAPA. Higher levels of evidence are now needed to lend further credence to the model’s capacity to make definitive evidencebased recommendations for health care policy and practice. This can be accomplished through research synthesis techniques as applied to the findings of existing studies and, most importantly, through the testing of interventions based on the continuous and stage-based versions of the model. Future empirical findings should be of significant interest to nurses, given the relevancy of the model’s outcome—the promotion of health-enhancing behaviors—to contemporary nursing practice.

SUMMARY The HAPA is a psychological theory of health behavior change that is used to assist nurse researchers in the conceptualization of a medication adherence neotheoretical model that subsequently informs the development and psychometric testing of the Reasoning and Regulating Medication Adherence Measurement Instrument. The key focus and strength of the HAPA are its consideration of both motivational and volitional factors that influence the uptake and maintenance of specific health behaviors. A growing body of evidence, mainly derived from psychology, tentatively supports the assumptions, concepts, and theoretical relationships outlined by the model. As acknowledged by developer Ralf Schwarzer, further evidence in the form of experimental trial designs is required to validate the model to the extent to which evidencebased practice and policy recommendations can be made. This point is reinforced when conducting a theoretical appraisal of the HAPA. Whereas the model can be evaluated as fulfilling the criteria of significance, internal consistency, parsimony, and testability, the extent to which the HAPA attains satisfactory empirical adequacy is debatable without such higher order levels of evidence. Evaluation of the criterion of pragmatic adequacy is also difficult due to the small number of studies that have been conducted in relation to nursing practice. Nevertheless, it is apparent that the HAPA can inform nursing ­practice in a meaningful way, particularly in the area of health promotion and in the development of complex interventions. Although the HAPA is not a nursing theory, it is a theory that attempts to explicate a phenomenon that is of significant concern to nurses. Therefore, whereas the nursing metaparadigm is not explicitly addressed, it is possible to relate the model to the metaparadigm concepts. The detailing in this chapter of the development of a medication adherence theoretical framework that in turn facilitated the ­generation of a new measurement instrument attests to the model’s potential contribution to professional practice. The key outcome of this research for nursing is a new and parsimonious interpretation of the cognitive-motivational and volitional self-regulatory processes that influence prolonged adherence to medication regimens. Whereas further nursing studies are needed to lend credence to the usefulness of the HAPA for clinical practice, the model holds significant promise for facilitating and enhancing evidence-based nursing contributions to patients’ health and well-being.



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Luszczynska, A. (2006). An implementation intentions intervention, the use of a planning strategy, and physical activity after myocardial infarction. Social Science & Medicine, 62, 900–908. Luszczynska, A., Goc, G., Scholz, U., Kowalska, M., & Knoll, N. (2011). Enhancing intentions to attend cervical cancer screening with a stage-matched intervention. British Journal of Health Psychology, 16(Pt 1), 33–46. Luszczynska, A., Sarkar, Y., & Knoll, N. (2007). Received social support, self-efficacy and finding benefits in disease as predictors of physical functioning and adherence to antiretroviral therapy. Patient Education & Counselling, 66, 37–42. Luszczynska, A., & Schwarzer, R. (2003). Planning and self-efficacy in the adoption and maintenance of breast self-examination: A longitudinal study on self-regulatory cognitions. Psychology and Health, 18, 93–108. Luszczynska, A., Tryburcy, M., & Schwarzer, R. (2007). Improving fruit and vegetable consumption: A self-efficacy intervention compared to a combined self-efficacy and planning intervention. Health Education Research, 22, 630–638. Maes, S., & Karoly, P. (2005). Self-regulation assessment and intervention in physical health and illness: A review. Applied Psychology: An International Review, 54, 267–299. Milnes, L. J., McGowan, L., Campbell, M., & Callery, P. (2013). Developing an intervention to promote young people’s participation in asthma review consultations with practice nurses. Journal of Advanced Nursing, 69(1), 91–101. Ogden, J. (2007). Health psychology: A textbook (4th ed.). Buckingham, England: Open University Press. Payaprom, Y., Bennett, P., Alabaster, E., & Tantipong, H. (2011). Using the Health Action Process Approach and implementation intention to increase flu vaccination uptake in high risk Thai individuals: A controlled before-after trial. Health Psychology, 30, 1–10. Renner, B., Kwon, S., Yang, B.-H., Paik, K.-C., Kim, S. H., Roh, S., . . . Schwarzer, R. (2008). Social-cognitive predictors of dietary behaviors in South Korean men and women. International Journal of Behavioral Medicine, 15(1), 4–13. Renner, B., & Schwarzer, R. (2005). Nutritional intentions as a mediator or moderator: Differences between intenders and non-intenders in terms of diet and social-cognitive variables. Polish Psychological Bulletin, 36(1), 7–15. Reuter, T., Ziegelmann, J. P., Wiedemann, A. U., & Lippke, S. (2008). Dietary planning as a mediator of the intention-behavior relation: An experimental-causal-chain design. Applied Psychology: An International Review [Special issue: Health and Well-Being], 57, 194–297. Richards, D. A., & Borglin, G. (2011). Complex interventions and nursing: Looking through a new lens at nursing research. International Journal of Nursing Studies, 48(5), 531–533. Richert, J., Reuter, T., Wiedemann, A. U., Lippke, S., Ziegelmann, J., & Schwarzer, R. (2010). Differential effects of planning and self-efficacy on fruit and vegetable consumption. Appetite, 54, 611–614. Scholz, U., Knoll, N., Sniehotta, F. F., & Schwarzer, R. (2006). Physical activity and depressive symptoms in cardiac rehabilitation: Long-term effects of a self-management intervention. Social Science and Medicine, 62, 3109–3120. Scholz, U., Schüz, B., Ziegelmann, J. P., Lippke, S., & Schwarzer, R. (2008). Beyond behavioral intentions: Planning mediates between intentions and physical activity. British Journal of Health Psychology, 13, 479–494. Scholz, U., Sniehotta, F. F., Burkert, S., & Schwarzer, R. (2007). Increasing physical exercise ­levels: Age-specific benefits of planning. Journal of Aging and Health, 19, 851–866.

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White, K. M., Terry, D. J., & Hogg, M. A. (1994). Safer sex behavior: The role of attitudes, norms, and control factors. Journal of Applied Social Psychology, 24, 2164–2192. Wiedemann, A. U., Lippke, S., Reuter, T., Schüz, B., Ziegelmann, J. P., & Schwarzer, R. (2009). Prediction of stage transitions in fruit and vegetable intake. Health Education Research, 24(4), 596–607. Ziegelmann, J. P., Lippke, S., & Schwarzer, R. (2006). Adoption and maintenance of physical activity: Planning interventions in young, middle-aged, and older adults. Psychology & Health, 21, 145–163.

chapter 8

The Judgment to Delay Model Máirín O’Mahony

This chapter presents the Judgment to Delay Model (J-Delay Model) (Facione, Miaskowski, Dodd, & Paul, 2002) and its application to research. Also discussed is the Common-Sense Model of Self-Regulation (CSM of Self-Regulation) (Leventhal, Brissette, & Leventhal, 2003). The chapter commences with a description of the J-Delay Model, its historical development, core concepts, and the relationships among those core concepts. The relationship of the J-Delay Model to the nursing metaparadigm concepts is outlined, followed by analysis and evaluation of the model generally and for use in research. This analysis incorporates application of the model to a study on women’s help-seeking behavior (HSB) and the associated influencing factors on selfdiscovery of a breast symptom (O’Mahony, McCarthy, Corcoran, & Hegarty, 2013).

BASIC DESCRIPTION OF THE MODEL The J-Delay Model The J-Delay Model emanates from a meta-analysis of studies (n = 12) on delay versus help-seeking for breast cancer symptoms (Facione, 1993) that uses social behavioral theory (Fishbein, 1979; Rosenstock, 1966; Triandis, 1979) as a structure for the analysis. Subsequently, the key concepts within the social psychological models of Ajzen and Fishbein (1980) and Triandis (1979), together with findings from previous qualitative studies (Facione & Dodd, 1995; Facione & Giancarlo, 1998; Facione, Giancarlo, & Chan, 2000), informed the development of the J-Delay Model (Facione et al., 2002, p. 398) (Figure 8.1). The J-Delay Model theoretically integrates factors associated with delay behavior (i.e., demographics, symptom appraisal, knowledge and beliefs, health-related habits, health service system issues, affective responses, relationship constraints, and personality attributes), all of which lead to problem resolution depicted as seeking evaluation (help-seeking) or patient delay (Facione et al., 2002). In the work reporting on the development and testing of the J-Delay Model, Facione et al. (2002) related how the model began with the “assumption that symptom appraisal is a cognitive decision-making process dependent on the estimation of potential risk posed by the symptom” (p. 398). They also suggested that “the decision to seek help or delay

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Part II  Theories Applied to Research Figure 8.1  Judgment to Delay Model (J-Delay Model).

Demographics (including age, educational level, income, cultural heritage)

PROBLEM DEFINITION Symptom Appraisal 1. Symptom knowledge 2. Risk attribution 3. Affective response

Relationship Constraints 1. Role obligations 2. Cultural expectancies 3. Family dynamics

PROBLEM RESOLUTION Seeking Evaluation vs Patient Delay

Beliefs and Knowledge 1. Of curability potential 2. Of the consequences of delay 3. In the influence of spirituality 4. In the efficacy of alternative therapies

Affective Responses 1. To the symptom 2. To the expected treatment Health Services System Variables 1. Perceived access 2. Economic constraints 3. Expectations of prejudice 4. Provider issues 5. Immigration issues Habits 1. Health services habits 2. Cancer screening habits 3. Self-care habits

Personality Attributes (including decision-making style, fatalism/optimism, coping style)

Reprinted with permission from Facione et al. (2002).

involves an intention formation” (p. 398). Using the J-Delay Model as a framework, it is proposed that women who are likely to delay can be identified and encouraged to seek help early through breast health promotion programs targeting those who are likely to hesitate (Facione et al., 2002). Facione et al. (2002) maintained that these variables to predict delay could identify women’s predisposition to postpone even before symptoms occur. Findings highlighted that, among a convenience sample (n = 699) of asymptomatic women recruited from community settings in the San Francisco Bay Area, 24% (n = 166) of women reported a likelihood to delay. Likelihood to delay help seeking was associated with: ●● ●● ●● ●● ●● ●● ●● ●● ●● ●● ●●

Lower income Lower educational level Identification as Latino or Black Having experienced prejudice in care delivery Perceived lack of access to health care Fatalistic beliefs about breast cancer Poor health care utilization habits Use of self-care behavior Perceived constraints from spouse/partner and employer Problem-solving style Lack of knowledge of breast cancer’s presenting symptoms (Facione et al., 2002)

The researchers concluded that self-reported likelihood of patient delay is measurable in advance of symptom occurrence. Hence, they deduced that successful targeting of women who are likely to hesitate could offer new potential to decrease advanced cancer at diagnosis. It was suggested that if women perceive themselves as likely to delay, this perception could be targeted by interventions aimed at early detection. Therefore, the model has potential for use in research on women’s HSB in the event of actual symptom discovery. Because the J-Delay Model was developed and



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tested with the intention of targeting women who are likely to delay, it did not allow for exploration of women’s beliefs about an actual breast symptom—as opposed to a potential symptom. Thus, the Self-Regulation Model (Leventhal, Meyer, & Nerenz, 1980) is reviewed in this regard because it has implications for research on women with breast symptoms.

The Self-Regulation Model The Self-Regulation Model, originally developed by Leventhal et al. (1980) and Leventhal, Nerenz, and Steele (1984), proposed that people construct cognitive representations of an illness/disease in order to understand and cope with a health problem. Initially, the model was labeled the Parallel Model to illustrate the interdependence between fear and danger control. According to Leventhal et al. (1980), cognitive representations include “beliefs about cause, cure, underlying mechanisms, and the effects of disease on coping behavior” (p. 17). In addition, people’s beliefs about illness duration (acute/chronic or cyclic) and past experience with illness and injury impact on their symptom attribution. These representations of illness, coping responses, and methods used for evaluating coping outcomes comprise “the complete self-­regulation system for control of danger/threat” (p. 23). Leventhal et al. (1980) proposed that peo­ple’s beliefs about illness are an integration of “common sense” perceptions of illness experiences, together with the views of the HCPs (health care practitioners); hence, the title CSM of Self-Regulation.

Common-Sense Model of Self-Regulation Later, in their description of the CSM of Self-Regulation, Leventhal et al. (2003) asserted that inherent in the model is the idea that people act as “common sense scientists” (p. 49) when creating representations of illness threats. These images help to develop goals for self-management. The cognitive process involves the formation of five illness representations regarding the symptom/threat: labeling (identity); perceived duration (timeline); perceived outcomes (consequences); internal and external agents (causes); and whether the disease/illness is perceived as preventable, curable, or controllable (controllability) (Leventhal et al., 2003, p. 50). These images then guide the selection and implementation of coping mechanisms such as symptom monitoring, self-medication, and help-seeking. Once the representations and coping strategies are linked to an action plan, the self-regulation is complete (Leventhal et al., 2003). Thus, the CSM of Self-Regulation (Leventhal et al., 2003) was deemed pertinent to the study of women’s beliefs concerning self-discovered breast symptoms and is outlined in the framework guiding the study (Figures 8.2 and 8.3). However, from here on, this chapter focuses on the J-Delay Model.

RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS MODEL The J-Delay Model was specifically developed for use in a study on women’s ­likelihood to delay seeking help for potential breast symptoms (Facione et al., 2002) and, to the author’s knowledge, has not been used by other disciplines. As already outlined, this model is based on social behavioral theory (Fishbein, 1979; Rosenstock 1966; Triandis, 1979), in particular the psychological models of Ajzen and Fishbein

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(1980) and Triandis (1979). It was also informed by qualitative studies (Facione & Dodd, 1995; Facione & Giancarlo, 1998; Facione et al., 2000) on women—both with and without breast symptoms—from various ethnic backgrounds in the San Francisco Bay Area of the United States.

MODEL ANALYSIS The J-Delay Model is now analyzed and evaluated using Fawcett’s (2005) framework for analysis and evaluation of nursing models. In examining the model, exploration of its origins is necessary. This should determine whether the philosophical claims on which the model is based are explicit. The J-Delay Model is based on the assumption that “symptom appraisal is a cognitive decision-making process aimed at estimation of the potential risk posed by the symptom” (Facione et al., 2002, p. 398). The authors also maintained that the intention to seek help is similar to an intention formation. The J-Delay Model incorporates the theoretically based concept groupings of the social psychological models (Ajzen & Fishbein, 1980; Triandis, 1979) together with findings from qualitative studies (Facione & Dodd, 1995; Facione & Giancarlo, 1998; Facione et al., 2000), outlining the key variables (Figure 8.1) proposed to impact on intentions to seek symptom evaluation. These theoretical and empirical foundations are addressed in the following text. According to Triandis’s (1979) theory of behavior, the variables of affect, perceived consequences, values of those consequences, social factors, habit, facilitating conditions, and physiological arousal all impact on the probability of a behavior occurring. The Theory of Reasoned Action (TRA) (Ajzen & Fishbein, 1980) also maintains that intended behavior is a function of both personal (attitude toward the behavior) and social determinants (the perceived social pressures to perform or not to perform a certain behavior; i.e., “subjective norm”) (Ajzen & Fishbein, 1980, p. 6). Findings from qualitative studies highlighted the impact of women’s symptom knowledge (Facione & Dodd, 1995), beliefs (conerning spirituality, alternative and complementary therapies, and self-care practices), and economic concerns about cost of care (Facione & Giancarlo, 1998; Facione et al., 2000) on their HSB and subsequent breast cancer diagnosis. Thus, the J-Delay Model has both theoretical and practical foundations. A second criterion of model evaluation relates to comprehensiveness of the model in terms of the depth and breadth of the content. According to Fawcett (2005), depth of a nursing model can be determined through its relevance to the metaparadigm concepts of person, health, environment, and nursing. Although not a nursing model, these metaparadigm concepts are expressed implicitly within the J-Delay Model (Facione et al., 2002). The J-Delay Model is health-oriented because it deals with resolution of a health problem (i.e., seeking evaluation [HSB] of a potential breast symptom) as opposed to delaying evaluation. The person is addressed in terms of demographics and personality attributes. The environment incorporates the variables proposed to impact on women’s HSB (i.e., women’s symptom-related knowledge and beliefs, relationship constraints, affective responses, health service system variables, and health and screening habits). Nursing is implicit in the model in that it was developed by a nurse researcher, and problem resolution (i.e., seeking evaluation of a breast symptom, whether potential or otherwise) explicates the nurse’s health-promoting role. Additionally, it is expected that the relational propositions of a nursing model would link all four metaparadigm concepts. In reviewing the J-Delay Model, the



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affiliated hypotheses are clear; it is proposed that people’s decisions to seek symptom evaluation or defer are influenced by various factors within their personal environment. Knowledge of these factors is important for nurses who have a major role to play in the promotion of prompt help-seeking for self-discovered breast symptoms. Breadth of a nursing model requires that it is sufficiently broad to guide nursing practice, although it may not be appropriate for all clinical situations in every culture (Fawcett, 2005). The J-Delay Model has the potential to guide health-promoting nursing activities regarding symptom evaluation and the decision to seek evaluation. Therefore, it is broad in its application to practice. Its development was based on research from various ethnic populations within the San Francisco Bay Area, suggesting that it is broad in its cultural perspective. Additional questions relate to the model’s ability to guide nursing research, education, and administration. The ideas of the J-Delay Model are clearly articulated (i.e., women’s decision to seek evaluation of their symptom or postpone is determined by the key variables outlined in the model) (Figure 8.1). Furthermore, the model was used in an Irish context to guide a recent study on women’s HSB for self-discovered breast symptoms (O’Mahony et al., 2013). Regarding education and administration, the model outlines the factors that potentially impact on women’s intentions to seek help or delay; thus, it can guide curriculum content and policy guidelines promoting women’s early help-seeking for breast cancer and other potential cancer symptoms. Third, the criterion of logical congruence is evaluated by addressing whether or not the components of the model reflect a logical interpretation of diverse perspectives (Fawcett, 2005). The J-Delay model integrates theoretically based variables with findings from previous qualitative studies. Thus, it combines both theoretical and person orientated perspectives on women’s intentions to seek evaluation for a potential breast symptom and does so in a logical, coherent way. Consequently, it combines both theoretical and person-oriented perspectives and does so in a logical, coherent way. A fourth criterion pertains to the model’s ability to lead to theory generation. Although the model has not led to theory generation as such, its concepts and premises are clearly articulated, allowing for testable hypotheses to be formulated in relation to women’s likelihood to defer help-seeking (Facione et al., 2002). In addition, the model was further adapted and utilized by the author to guide the study on women’s actual HSB for self-discovered breast symptoms (O’Mahony et al., 2013). Therefore, it can be said that the J-Delay Model facilitates generation of knowledge that has potential to lead to theory generation. Fifth, the criterion of credibility of the nursing model is determined by establishing its social utility, congruence, and significance. Social utility relates to whether the model can guide research, education, administration, and practice. The model was used to guide the study of women’s intentions to delay help-seeking for hypothetical symptoms (Facione et al., 2002). Following further review of the literature, it was adapted (Figures 8.2 and 8.3) and used to guide the study on women’s HSB for actual breast symptoms (O’Mahony et al., 2013). Apart from symptom beliefs and emotional factors relating to symptom discovery, the key concepts of this study—knowledge relating to symptom identity, breast changes associated with breast cancer, family history of breast cancer, beliefs around alternative help-seeking behaviors, social factors, health-seeking habits, and health service system utilization—were operationalized using valid and reliable scales developed by Facione et al. (2002). In terms of education, the J-Delay Model highlighted the possibility of identifying women who are likely to delay. Hence, the possibility of developing interventions to promote early

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detection is realized. The use of the model in the study on women with breast symptoms (O’Mahony et al., 2013) accentuated that it is of benefit to HCPs involved in promoting early evaluation of breast cancer and all potential cancer symptoms. The model has the potential to guide education and administration in terms of its relevance to future curriculum and health policy development around HSB for prompt evaluation of symptoms associated with breast cancer. Social congruence refers to the compatibility of the nursing activities emanating from the nursing model with individuals’ and communities’ expectations for nursing practice. In this regard, the J-Delay Model outlines the many factors proposed to impact on women’s decisions to seek evaluation of a possible breast cancer symptom. Therefore, the model pertains to an issue that is important to individuals and communities in the effort to reduce the impact of breast cancer on women and their significant others through early detection, diagnosis, and treatment. Social significance of a nursing model is calculated by its social value: Does the model have a positive impact on the well-being of the population (Fawcett, 2005)? In outlining the factors associated with delay behavior, the J-Delay Model stresses issues that need to be considered when promoting early help-seeking for self-discovered breast symptoms. Thus, the model has immense social significance for contemporary society, where early detection of breast cancer is high on the cancer control agenda. Finally, the contribution of the model to the discipline of nursing needs to be illustrated. The J-Delay Model, although not a nursing model, has the viability to contribute to the discipline of nursing as it pertains to the issue of breast symptom evaluation and illuminates the ramifications that have potential to impact on the decision to seek evaluation or delay. It has guided research on women’s possibility to delay (Facione et al., 2002) and women’s HSB for actual breast symptoms (O’Mahony, Hegarty, & McCarthy, 2011; O’Mahony et al., 2013). Therefore, its contribution to nursing and to HCPs, generally, is evident.

USE OF THE MODEL IN THIS RESEARCH The application of the J-Delay Model to the study of women’s HSB and the associated influencing factors on self-discovery of a breast symptom (O’Mahony et al., 2013) is detailed in this section. Subsequent to review of the theoretical literature concerning the concept of HSB, a preliminary conceptual framework—combining the key concepts of the J-Delay Model (Facione et al., 2002) and the illness representations of the CSM of Self-Regulation (Leventhal et al., 2003)—was developed and used to guide the literature review for a study on women’s HSB following symptom discovery (Figure 8.2). The ensuing literature review led to the development of the conceptual framework for help-seeking behavior and associated influencing factors (Figure 8.3) that guided the methodology, presentation of findings, and discussion phases of the study. This configuration outlines the factors influencing HSB on self-discovery of a breast symptom, and was largely informed by the research of Facione et al. (2002); Meechan, Collins, and Petrie (2002, 2003); Leventhal et al. (2003); O’Mahony and Hegarty (2009); and O’Mahony et al. (2013). Within this conceptual structure, knowledge relates to women’s expertise on symptom identity, the presence or absence of a family history of breast cancer, and breast changes associated with breast cancer. Beliefs relate to what women believe about their breast symptoms and the possible outcomes of



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Figure 8.2  Preliminary framework on help-seeking behavior (HSB) for self-discovered breast symptoms. Knowledge and Beliefs: Identity (interpretation of symptom/symptom type), cause (risk attribution), timeline (likely duration of illness and symptom), consequences (perceived severity of symptom and impact of illness), curability (extent to which symptom/illness can be cured or controlled)

Psychological Factors

Social Factors

Health Service System Utilization

Health-Seeking Habits

Sociodemographic Factors

Delayed Diagnosis and Treatment

Patient Delay

Help-Seeking Behavior (HSB)

Patient Seeks Help

Prompt Diagnosis and Treatment

Adapted from Facione et al. (2002), Leventhal et al. (2003), O’Mahony (2011).

the symptom. Precepts about women’s breast symptoms are categorized according to the theoretical underpinnings of the CSM of Self-Regulation Model (Leventhal et al., 2003). In this research, these dimensions focused on women’s beliefs regarding their current breast symptom. Because women were presenting with an actual breast symptom, they were asked to identify their symptom from a list of breast cancer–associated symptoms. Tenets also related to women’s beliefs in the use of “alternative help-seeking behaviors” (involving r­ eligiousness/prayer) on symptom discovery. The remaining variables within the framework reflect the concepts within the J-Delay Model (Facione et al., 2002) and the feedback from the literature review. Emotional responses relate to the extent to which women felt “afraid, anxious, distressed, depressed, angry, unsure/uncertain” on discovery of their breast symptom (Meechan et al., 2003; O’Mahony & Hegarty, 2009). Social factors are concerned with women’s roles, responsibilities and commitments, and disclosure of the symptom to another person. In addition, relationship status and living arrangements are addressed with sociodemographics. Health service system utilization aspects deal with women’s perceived access to health care in terms of cost, convenience, relationship with an HCP, and their perceptions of experienced prejudice within the health system. Health-seeking habits involve frequency of performance of breast self-­examination and frequency of mammography screening. Sociodemographic features include women’s age, nationality, educational level, and employment status. Finally, HSB is determined by recording the time period (in weeks) from initial symptom discovery up to the time of visiting the general practitioner (GP), the outcome of which could be prompt or delayed HSB (Figure 8.3).

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Part II  Theories Applied to Research Figure 8.3  The conceptual framework of help-seeking behavior (HSB) and associated influencing factors used to guide the study design developed from an amalgamation of the empirical and theoretical literature. Knowledge: Regarding breast symptom identity; breast changes associated with breast cancer; presence/absence of a family history of breast cancer Beliefs: Relating to symptom cause, timeline (duration of symptom), consequences, curability (extent to which symptom/illness can be cured or controlled), attribution or outcome (the use of alternative help-seeking behaviors [HSBs])

Delayed Diagnosis and Treatment (if necessary)

Emotional Responses Afraid, anxious, distressed, scared, depressed, angry, unsure/uncertain

Patient Delay

Social Factors Role obligations Symptom disclosure Health-Seeking Habits Breast self-examination Mammography

Help-Seeking Behavior (HSB) for Breast Cancer Symptoms

Health Service System Utilization Perceived access: Cost, convenience, relationship with HCP, personal experiences of prejudice Sociodemographic Factors Age, nationality, relationship status, living arrangements, occupation, health insurance/free medical care, educational level

Patient Seeks Help

Early Diagnosis and Treatment (if necessary)

HCP, health care practitioner. Adapted and reprinted from Facione et al. (2002), Leventhal et al. (2003), Meechan et al. (2002, 2003), O’Mahony and Hegarty (2009), O’Mahony et al. (2011, 2013). Used with permission from Elsevier Limited.

The HSB and influencing factors framework was validated using a qualitative descriptive study (n = 10) (O’Mahony et al., 2011). This observation expanded knowledge and understanding of women’s HSB on self-discovery of a breast symptom, and illuminated the key variables linked to delayed help-seeking (i.e., emotional responses, social factors, knowledge, and beliefs). In particular, the importance of questioning women on their denial was highlighted. The research also reiterated the significance of questioning women on their knowledge and beliefs concerning their breast symptom, their fear surrounding symptom discovery, and the impact of family and work commitments on their HSB. Data demonstrated that the variables within the HSB and influencing factors profile act both as facilitators and barriers to women’s HSB (O’ Mahony et al., 2011). Thus, the appropriateness of this conceptual framework for a quantitative study of symptomatic women was confirmed. Use of the structure for the study of women’s HSB following breast symptom discovery is now analyzed. The evaluative criteria (Fawcett 1999) for theory selection in research, adapted from Bredow (2004), are used to examine the application of the J-Delay Model to the study of women’s HSB following self-discovery of a breast symptom. Key questions



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for investigators to consider when applying a theory to research refer to its fit, operationalization, performance, relevance to the research hypotheses, and whether the model flows from the research question. Additionally, the study questions, assumptions, clinical outcomes, and research tools available to test relationships within the theory need to be addressed (Table 8.1).

Table 8.1 Evaluative Criteria for Use of the J-Delay Model to Guide the Study on Women’s Help-Seeking Behavior (HSB) for Self-Discovered Breast Symptoms Questions for evaluation

Responses to questions

1.

Does the model fit the research that you wish to do?

The J-Delay Model (Figure 8.1) (Facione et al., 2002) represents the factors influencing women’s intentions to delay HSB for hypothetical self-discovered breast symptoms; further development was required to address the current research question regarding women’s HSB for actual breast symptoms (Figure 8.3).

2.

Is it readily operationalized?

The model was readily operationalized for women who were asymptomatic; however, it needed further development for application to a study on women with actual breast symptoms (Figure 8.3).

3.

How well has the model performed at describing, predicting, and/or explaining the phenomena to which it relates?

The model has been used to describe, explain, and predict women’s likelihood to delay HSB for hypothetical self-discovered breast symptoms (Facione et al., 2002). Its use in the current study facilitated the description and explanation of women’s HSB for actual breast symptoms and the associated factors impacting on their HSB.

4.

Does the model relate to and address the research hypotheses in its description and explanation?

The development of the model (Figure 8.3) to the help-seeking behavior (HSB) and associated influencing factors’ conceptual framework relates to and addresses the research hypotheses because it outlines the key factors proposed to influence women’s HSB in the event of breast symptom discovery in terms of their decision to delay or seek help promptly.

5.

Does the model flow from the research question?

The J-Delay Model serves to predict women’s likelihood to delay help-seeking for potential breast symptoms. Subsequently, the conceptual framework (Figure 8.3) was developed from an amalgamation of the theoretical and empirical literature to address the question regarding what women do when they discover a breast symptom. Thus, the J-Delay Model informed the framework that emanated from the research questions around women’s HSB.

6.

Does the model address the primary and secondary research questions?

The J-Delay Model focuses on women’s intentions to delay (or seek) evaluation for hypothetical breast symptoms. The final conceptual framework (Figure 8.3) addresses the primary and secondary research questions (i.e., to describe women’s HSB and the associated influencing factors in the event of actual breast symptom discovery). (continued)

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Table 8.1 Evaluative Criteria for Use of the J-Delay Model to Guide the Study on Women’s Help-Seeking Behavior (HSB) for Self-Discovered Breast Symptoms (continued) Questions for evaluation

Responses to questions

7.

Are the assumptions congruent with the assumptions that are made for research?

The J-Delay Model is congruent with the assumptions made for research in that it theoretically links factors related to HSB to hypothetical symptoms. Subsequently, the assumptions within the adapted conceptual framework (Figure 8.3) are congruent with the assumptions for research: There is a directional relationship proposed between women’s knowledge, beliefs, emotional responses, social factors, health-seeking habits, health service system utilization, sociodemographic factors, and their HSB (i.e., whether they delay or seek help promptly) for self-discovered breast symptoms.

8.

Is the model oriented to outcomes that are critical to patients?

The J-Delay Model is oriented to outcomes that are critical for women in terms of predicting their likelihood to delay helpseeking for potential breast symptoms. Similarly, the HSB and associated influencing factors’ conceptual framework outlines factors proposed to influence women’s HSB in the event of actual symptom discovery. Knowledge emanating from research using the model/framework is crucial in terms of promoting prompt detection and early diagnosis of breast cancer.

9.

Are tools available to test relationships of the model or do they need to be developed?

The J-Delay Model was tested using the Breast Cancer Symptom Knowledge Scale, Self-Care Scale, Perceived Access to Health Services (PAHS), Personal Experience of Prejudice (PEP), and Judgment to Delay (J-Delay) Scale (Facione et al., 2002). Apart from the J-Delay Scale, these tools were adapted together with the Illness Perception Questionnaire (Weinman et al., 1996) and the Psychological Distress Scale (Meechan et al., 2003; O’Mahony & Hegarty, 2009) to test the relationships proposed in the HSB and associated influencing factors (Figure 8.3) framework.

In considering whether the J-Delay Model (Figure 8.1) fits the research question, the model represents the factors influencing women’s intentions to delay HSB for hypothetical self-discovered breast symptoms (Facione et al., 2002). The model was developed from social psychological theory and previous qualitative studies involving some women who had experienced breast cancer symptoms; therefore, it has relevance to the study of women with breast symptoms. Although the model was readily operationalized in relation to women’s potential to delay or seek evaluation, it needed further development for application to exploring the reality of women’s experience of symptom discovery and HSB. The primary usage of the model was to review women’s intentions to seek evaluation or delay (Facione et al., 2002), and thus determine its ability to predict women who are likely to delay. The model outlines factors likely to have an impact on delayed HSB and lead to the design of research hypotheses concerning women’s possibility to delay (Facione et al., 2002). Testing of the model led to description and explanation of women’s intentions about symptom



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evaluation. However, whereas symptom examination is expected to occur in certain instances, it is not always certain that it occurs in reality (DeNooijer, Lechne, & deVries, 2002); thus, the J-Delay Model needed further advancement for operation in a study on women’s HSB for symptom discovery (Figure 8.3). This development was facilitated by an in-depth review of the literature and a qualitative study on a sample (n = 10) of women with breast symptoms (O’Mahony et al., 2011). In addressing whether the model flows from the research question, the J-Delay Model was initially designed to depict the factors proposed to impact on women’s HSB for potential breast symptoms. Further adaptation and enhancement (Figure 8.3) enabled its use in the study of women’s HSB for actual breast symptoms. Accordingly, the model guided the development of a construction to treat the research ­questions around women’s HSB. Subsequently, this framework was used to answer the primary and secondary research questions that are reflected in the aim of the exercise (i.e., to describe women’s HSB and the associated influencing factors on self-discovery of a breast symptom) (O’Mahony et al., 2013). Congruence of the J-Delay Model’s assumptions with those of the research is calculated because the model speculatively integrates factors that are related to delay behavior for hypothetical symptoms as highlighted in the theoretical and empirical literature (Facione et al., 2002). Nevertheless, following further review of the theoretical and empirical literature, it was expanded to depict the process of HSB and the components proposed to influence HSB for actual breast symptoms (Figure 8.3). Orientation of the J-Delay Model to outcomes that are critical to patients is evident in that delayed evaluation of breast symptoms has the possibility of leading to delayed diagnosis and treatment of breast cancer. Similarly, employment of the HSB and associated influencing factors framework (Figure 8.3) identified that delayed help-seeking continues to occur among some women who self-discover breast symptoms (O’Mahony et al., 2013). The configuration also facilitated clarification of the key factors associated with delay (i.e., the presenting nonlump symptom of “nipple indrawn/changes”; women’s belief in “ignoring the symptom and hoping it would go away”; and their perceptions of longer symptom duration). Conversely, fear on symptom discovery was associated with less hesitation. Thus, delayed HSB was influenced predominantly by women’s knowledge of presenting symptoms, as well as their beliefs concerning denial of the symptom and longer symptom duration. Knowledge from the study of women’s HSB following discovery of breast symptoms should lead to refinement and further enhancement of key messages and interventions designed to promote prompt help-seeking for self-discovered breast symptoms. Timely help-seeking has the feasibility to lead to early diagnosis and better outcomes for women who are diagnosed with breast cancer (Richards, 2009; Richards, Westcombe, Love, Littlejohns, & Ramirez, 1999). Thus, orientation of the original J-Delay Model and its further development to outcomes that are critical to patients (i.e., women with breast symptoms) is clearly evident. Finally, Fawcett’s (1999, 2005) criteria question whether tools are available to test the relationships of the model or whether they need to be developed. Facione et al. (2002) developed the Breast Cancer Symptom Knowledge (BCSK), Self-Care, Perceived Access to Health Services (PAHS), Personal Experience of Prejudice (PEP), and Judgment to Delay (J-Delay) scales for use in the research on women’s intentions to delay for potential breast symptoms. Apart from the J-Delay scale, these devices were adapted and used in the study of women’s HSB (Figure 8.3).

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The BCSK scale assessed women’s expertise relating to breast changes associated with breast cancer. This scale was adapted (n = 8) to reflect the recognized breast symptoms associated with breast cancer. Women were asked to identify their breast symptom(s) from a list of recognized breast symptoms (­ American Cancer Society, 2009; Health Service Executive [HSE], 2009; Irish Cancer Society, 2011). Facione and colleagues’ (2002) eight-item Self-Care Scale measured women’s intended self-care practices relating to possible breast symptoms. It was adapted (n = 8) to interpret women’s alternative HSB following breast symptom discovery. Women were asked whether or not they engaged in/believed in a range of other HSBs—such as “meditating about the problem,” “praying to God,” or “visiting an alternative therapist”—upon finding their breast symptom. Women’s health service system utilization (in terms of convenience to health services, cost of services, and the existence of a relationship with an HCP) was measured by an adaptation (n = 11) of the PAHS scale (Facione et al., 2002). Women’s personal experience of prejudice (PEP) in health care delivery and its impact on HSB was measured by the PEP subscale (Facione & Facione, 2007). This four-item scale was incorporated into the end of the PAHS scale. Furthermore, the Illness Perception Questionnaire (Weinman, Petrie, MossMorris, & Horne, 1996) was adjusted to determine women’s beliefs regarding the cause, duration, consequences, and curability/controllability of their breast symptom. The Symptom Emotional Distress Scale (Meechan et al., 2003; O’Mahony & Hegarty, 2009) provided a valid and reliable tool to measure women’s emotional responses (i.e., fear, anxiety, distress, depression, anger, uncertainty) to their breast symptom. Thus, the J-Delay Model supplied a basis for the development of the HSB and associated influencing factors structure (Figure 8.3). In turn, this framework guided the study on women’s HSB following breast symptom discovery. The J-Delay Model led to the design of valid and reliable instruments to measure women’s likelihood to delay help-seeking. Subsequently, these devices were tailored to deliver sound and authentic determinants of the factors influencing women’s actual HSB following breast symptom discovery. These tools clarified the key items leading to women’s delayed HSB (i.e., women’s knowledge about nonlump breast symptoms, their belief in the alternative HSB of “ignoring the symptom and hoping it would go away,” and their belief in longer symptom duration). Conversely, the model led to the conclusion that fear, upon symptom discovery, facilitated prompt HSB. Therefore, the model clearly meets the criteria for theory selection in research.

RECOMMENDATIONS FOR FURTHER RESEARCH The J-Delay Model (Facione et al., 2002) formed the basis for development of the HSB and influencing factors configuration to guide the study of women’s HSB following breast symptom discovery (O’Mahony et al., 2013). Hence, the relevance of the framework to the study of women with actual breast symptoms was confirmed. However, further qualitative research with women who found a breast symptom is necessary in order to evolve a theory on HSB for self-discovered breast symptoms. Additionally, a study focusing particularly on women who waited for 3 months or more would further clarify the issues around delay, and illuminate the factors influencing hesitation from the woman’s perspective. This theory would augment the current



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findings and add to the body of information around HSB for self-­discovered breast symptoms. Such knowledge would facilitate the development and/or refinement of an intervention to promote prompt HSB following breast symptom discovery—for women across their life span. It could also be useful to HCPs who are involved in the advancement of policies and guidelines promoting early detection, diagnosis, and treatment of breast cancer. Furthermore, these data have the potential to transcend HSB for other cancer-related symptoms.

SUMMARY This chapter presents the J-Delay Model (Facione et al., 2002) and describes its application to a study on women’s HSB for self-discovered breast symptoms (O’Mahony et  al., 2013). The CSM of Self-Regulation (Leventhal et al., 2003) is also outlined because it is used to operationalize women’s beliefs concerning their breast symptom. The J-Delay Model is analyzed and evaluated in terms of its relevance to the metaparadigm of nursing. In addition, Fawcett’s (2005) framework for analysis and evaluation of nursing models is used to investigate and explore the J-Delay Model from a general perspective. Subsequently, Fawcett’s (1999, 2005) criteria are used to examine the appropriateness of the J-Delay Model to the development of the HSB and influencing factors structure to guide the study of women’s HSB and the associated influencing factors on self-discovery of a breast symptom (O’Mahony et al., 2013). Finally, recommendations are outlined for further research to elevate this framework to a theoretical level and augment the body of knowledge on HSB for self-discovered breast cancer symptoms. In conclusion, the development of nursing knowledge necessitates the use of theoretical frameworks, models, or conceptual frameworks to guide nursing research. However, investigators need to clearly articulate exactly what they are using, and employ the necessary criteria to analyze and evaluate relevance and appropriateness for nursing research. Clarity in these issues is vital for continued enhancement of expertise for the discipline of nursing.

References Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Upper Saddle River, NJ: Prentice Hall. American Cancer Society. (2009). Breast cancer facts & figures 2009–2010. Atlanta, GA: Author. Bredow, T. S. (2004). Analysis, evaluation and selection of a middle range nursing theory. In S. J. Peterson & T. S. Bredow (Eds.), Middle range theories: Application to nursing research (pp. 42–56). Philadelphia, PA: Lippincott Williams & Wilkins. DeNooijer, J., Lechne, L., & deVries, H. (2002). Early detection of cancer: Knowledge and behavior among Dutch adults. Cancer Detection and Prevention, 26, 362–369. Facione, N. C. (1993). Delay versus help seeking for breast cancer symptoms: A critical review of the literature on patient and provider delay. Social Science and Medicine, 36, 1521–1534. Facione, N. C., & Dodd, M. (1995). Women’s narratives for helpseeking for breast cancer. Cancer Practice, 3, 219–225. Facione, N. C., & Facione, P. A. (2007). Perceived prejudice in healthcare and women’s health protective behaviour. Nursing Research, 56(3), 175–184.

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Part II  Theories Applied to Research Facione, N. C., & Giancarlo, C. A. (1998). Narratives of breast symptom discovery and cancer diagnosis: Psychologic risk for advanced cancer at diagnosis. Cancer Nursing, 21, 430–440. Facione, N. C., Giancarlo, C. A., & Chan, L. (2000). Perceived risk and help-seeking behavior for breast cancer: A Chinese-American perspective. Cancer Nursing, 23 (4), 258–267. Facione, N. C., Miaskowski, C., Dodd, M. J., & Paul, S. M. (2002). The self-reported likelihood of patient delay in breast cancer: New thoughts for early detection. Preventive Medicine, 34, 397–407. Fawcett, J. (1999). The relationship of theory and research. Philadelphia, PA: F. A. Davis. Fawcett, J. (2005). Analysis and evaluation of contemporary nursing knowledge: Nursing models and theories (2nd ed.). Philadelphia, PA: F. A. Davis. Fishbein, M. H. (1979). A theory of reasoned action: Some applications and implications. Nebraska Symposium on Motivation, 27, 65–116. Health Service Executive (HSE). (2009). National breast cancer GP referral guidelines. Dublin, Ireland: Author. Irish Cancer Society. (2011). Breast awareness-action breast cancer. Retrieved from http//www .cancer.ie/action/breastawareness Leventhal, H., Brissette, I., & Leventhal, E. A. (2003). The Common-Sense Model of SelfRegulation of Health and Illness. In D. C. Cameron & H. Leventhal (Eds.), The self-regulation of health and illness behavior (pp. 42–65). London, England: Routledge. Leventhal, H., Meyer, D., & Nerenz, D. (1980). The common sense representation of illness and danger. In S. Rachman (Ed.), Medical psychology (pp. 7–30). New York, NY: Pergamon Press. Leventhal, H., Nerenz, D., & Steele, D. J. (1984). Illness representations and coping with health threats. In A. Baum, S. E. Taylor, & J. E. Singer (Eds.), Handbook of psychology and health (Vol. IV, Social psychological aspects of health, pp. 219–252). Hillsdale, NJ: Erlbaum. Meechan, G., Collins, J., & Petrie, K. J. (2002). Delay in seeking medical care for self-detected breast symptoms in New Zealand women. New Zealand Medical Journal, 115, U257. PMID: 12552275 Meechan, G., Collins, J., & Petrie, K. J. (2003). The relationship of symptoms and psychological factors to delay in seeking medical care for breast symptoms. Preventive Medicine, 36, 374–378. O’Mahony, M. (2011). Women’s help seeking behavior and the associated influencing factors on selfdiscovery of a breast symptom (Unpublished PhD thesis). University College Cork, Ireland. O’Mahony, M., & Hegarty, J. (2009). Factors influencing women in seeking help from a health care professional on self-discovery of a breast symptom, in an Irish context. Journal of Clinical Nursing, 18(14), 2020–2029. O’Mahony, M., Hegarty, J., & McCarthy, G. (2011). Women’s help seeking behavior for selfdiscovered breast cancer symptoms. European Journal of Oncology Nursing, 15, 410–418. O’Mahony, M., McCarthy, G., Corcoran, P., & Hegarty, J. (2013). Shedding light on women’s help seeking behaviour for self discovered breast symptoms. European Journal of Oncology Nursing, 17(5), 632–639. doi:10.1016/j.ejon.2013.03.012 Richards, M. A. (2009). The size of the prize for earlier diagnosis of cancer in England. British Journal of Cancer, 101 (suppl. 2), S125–S129. Richards, M. A., Westcombe, A. M., Love, S. B., Littlejohns, P., & Ramirez, A. J. (1999). Influence of delay on survival in patients with breast cancer: A systematic review. The Lancet, 353 (9159), 1119–1126. Rosenstock, I. M. (1966). Why people use health services. The Milbank Memorial Fund Quarterly, 44(3), 94–124.



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Triandis, H. C. (1979). Values, attitudes, and interpersonal behavior. Nebraska Symposium on Motivation, 27, 195–259. Weinman, J., Petrie, K. J., Moss-Morris, R., & Horne, R. (1996). The Illness Perception Questionnaire: A new method for assessing the cognitive representation of illness. Journal of Psychology and Health, 11, 431–445.

chapter 9

The Progressively Lowered Stress Threshold Model Mark P. Tyrrell

The Progressively Lowered Stress Threshold (PLST) Model was developed by nurse academics Hall and Buckwalter in 1985, and evolved from an understanding of behaviors of persons with dementia in the context of person–environment fit (Hall & Buckwalter, 1987). It proposes that a person has a stress threshold that is more or less set in adulthood; however, this can be temporarily altered during times of illness or permanently altered during episodes of brain damage, as is the case in dementia. When this threshold is breached, the person may begin to exhibit problem behaviors such as aggression, agitation, wandering, sexual disinhibition, noisy behavior, anxiety, compulsive repetitive actions, and compulsive repetitive verbalizations. People with dementia, therefore, have a diminished ability to interact with their environment. They find things in their environment confusing because their brains are no longer able to process information accurately. The model proposes, therefore, that “persons with dementia need environmental conditions modified as they experience progressive cognitive decline so that cues can be more easily processed and are thus less stressful” (Smith, Gerdner, Hall, & Buckwalter, 2004, p. 1756).

BASIC DESCRIPTION OF THE THEORY The PLST Model was developed by Hall and Buckwalter in the mid-1980s, after many years of observation and clinical practice with people suffering from Alzheimer’s disease or a related dementia (ADRD) (Hall & Buckwalter, 1987). This also coincided with a time when federal legislation in the United States concerning nursing home care changed with regard to the use of physical restraints to control behavioral symptoms among residents—thus heralding a need for alternative interventions for managing these behaviors (Richards & Beck, 2004). One particular observation by Hall (1998) was that despite differences in people’s personalities and their general symptom presentation, many secondary behavioral symptoms—such as agitation, wandering, social withdrawal, and aggression and violence—are common among people with dementia. Also, these generally present late in the day; are exacerbated by fatigue; and frequently

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are associated with a stressful event such as a social activity, a shopping trip, or a special event such as a wedding. Hall (1998) noted that family caregivers frequently reported that the care recipient became upset by these events and often tried to avoid them or to escape from them. Moreover, people with dementia were also observed to exhibit more secondary symptoms during holidays or at other times when changes in routine or environment were inevitable. Hall (1998) argued that secondary symptoms make caregiving difficult because people with dementia do not respond to traditional care interventions in the way that one would expect a lucid individual to respond. This frequently results in family caregivers resorting to pharmacological approaches to managing behaviors; however, many of these behaviors are not amenable to pharmacological intervention (Maletta, 1992). Hall and Buckwalter formed the view that many of these behaviors were stress-related and occurred in situations where the demands of external stimuli exceeded the person’s adaptive ability. They hypothesized, therefore, that these behaviors could best be managed by recognizing the situations in which they occurred in order that these situations could be avoided in the future. Essentially, this meant understanding and managing stress in the care recipient’s environment of care. In developing the PLST Model, Hall and Buckwalter (1987) drew on these observations from clinical practice and on a number of existing theories that they felt helped explain secondary behaviors in dementia. These included theories of person– environment fit/interaction (Kahana, 1975; Lawton, 1975; Lewin, 1951); theories of acute confusion (Wolanin & Philips, 1981); theories of coping (Lazarus, 1966); the Environmental Docility Hypothesis (Lawton & Nahemow, 1973); and stress theory (Selye, 1980; Verwoedt, 1981). One of the first researchers to explicate the relationship between person and environment was the psychologist Lewin (1951), who proposed that behavior is a function of both people and their environments. Later, Lawton (1975) noted that for people with cognitive impairment, the ability to receive, process, and make sense of environmental cues is compromised, thus making it increasingly difficult for the individual to cope with everyday environmental stimuli. These theories were seen to explain how people with dementia, because of their progressive cognitive impairment, exhibit behaviors that are indicative of disordered person–environment interaction (Hall & Buckwalter, 1987; Smith et al., 2004). These include an “inability to recognize once-familiar objects, the purpose of the objects, and how to use them; inability to recognize family and friends; repetitive behaviors; catastrophic reactions; and situationally inappropriate behaviors” (Smith et al., 2004, p. 1756). Lazarus (1966), in reviewing factors associated with human beings’ coping responses, identified four biological mechanisms that are essential for effective coping, namely: the ability to move; the ability to produce energy; the ability to sense and perceive; and the ability to integrate mechanisms within the cerebral cortex. Hall and Buckwalter (1987) observed that all of these biological mechanisms are progressively impaired in people with ADRD, resulting in a continual decline in the person’s ability to cope with internal and external stressors. This observation was also congruent with Lawton and Nahemow’s (1973) docility hypothesis, the main thesis of which is that as competence decreases, external environmental factors become increasingly important determinants of behavior and mood for people with dementia. If environmental stimuli go beyond a person’s adaptive level, “ . . . the limits set by the person’s competence are surpassed and the behavioral and affective outcomes are negative” (Kovach, 2000, p. 380). Lawton (1986) was of the view that people with low levels of competence (such as people with progressive dementia)



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need a reduced amount of environmental stimuli. Accordingly, this hypothesis also argued that functional behavior was likely to occur when the external demands (stimuli) on the person with dementia were adjusted to their level of adaptation. Hall and Buckwalter’s observations also echoed aspects of Verwoedt’s (1981) and Selye’s (1980) theories on stress. Verwoedt (1981) attempted to explain dysfunctional behavior in people with dementia as “primary anxiety resulting from an overwhelming influx of internal or external stimuli” (Hall & Buckwalter, 1987, p. 401). This means that when the person is unable to overcome the stress of these overwhelming stimuli, psychological states of stress are created culminating in alterations in behavior and mental mechanisms, resulting in dysfunctional behavior (Hall, 1998). Similarly Selye (1980), in explicating his General Adaptation Syndrome (GAS), argued that people with dementia who undergo prolonged high levels of stress experience excessive functional impairment; however, this will abate if and when the stresses are removed. Hall and Buckwalter (1987) observed that the secondary behaviors of dementia are also congruent with theories of acute confusion suggested by Wolanin and Philips (1981). They noted that these behaviors are “both cognitively and socially inaccessible” (Hall, 1998, p. 72), meaning that the person exhibiting the behavior is experiencing a temporary increase in cognitive disability and an inability to communicate effectively during the episode. The development of the PLST Model was also influenced by findings from dementia research from the 1970s and early 1980s. Hall (1998) reported that much of the lay and professional literature at that time regarding the care of people with dementia advocated care strategies such as reality orientation, patient rehabilitation through the use of maximum sensory input, and assisting the person with dementia to relearn lost skills. Moreover, the practice of keeping a person who wakens at night awake during the day was also common at the time. According to Hall and ­Buckwalter (1987), these practices were based on the beliefs that people with cognitive impairment needed increased stimulation in order to compensate for their lost abilities; that secondary behaviors such as wandering, confusion, and aggression were inevitable and unpreventable; and that increasing individuals’ levels of activity would fatigue them and help them sleep better at night. These practice recommendations, however, were at odds with clinical experience in dementia care, in that strategies such as these were observed to increase a person’s stress and hence were more likely to lead to secondary behavioral symptoms (Hall, 1998). Keeping a person awake during the day, for example, was observed to be more likely to lead to increased night-time agitation, wandering, and wakefulness. With these theories in mind, the PLST Model was developed to explain the interaction of persons with dementia with their environments, in order that caregivers could rapidly assess behavioral problems in care recipients and subsequently modify the environment to reduce stressors—the result of which was that care recipients returned to baseline (back to within their stress threshold).

CORE CONCEPTS Hall and Buckwalter (1987) subsequently derived a number of assumptions based on their analysis of this literature and these influencing theories: ●●

All human beings require some control over their person and their environment and need some degree of unconditional positive regard.

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All behavior is rooted and has meaning; therefore, all catastrophic and stressrelated behaviors have a cause. The confused or agitated person is not comfortable and should be regarded as frightened. All people have the right to be comfortable. The impaired person exists in a 24-hour continuum. Care cannot be planned or evaluated on an 8-hour-shift basis. If the person has problems at night, changes need to be implemented during the day. (Hall, 1998, p. 74)

Hall and Buckwalter also noted attempts by researchers in the early 1980s to identify and categorize the myriad of behavioral symptoms of dementia that existed (Hall, 1998). Three clusters emerged from this work: cognitive or intellectual losses, affective or personality losses, and conative or planning losses. A number of symptoms were attributed to each cluster. Hall (1998) points out that people with ADRD could present with one or more symptoms from each cluster, and that this was evidence of the varieties in disease presentation among individuals with dementia. It is also evident from this early work that researchers were experiencing difficulty in fitting some other behaviors (such as agitation, avoidance, and night waking) into any of the established cluster groups. Symptoms such as these were clearly a feature of ADRD; however, they did not fit within existing categories. As a result, Hall and Buckwalter (1987) proposed a fourth cluster to accommodate these “stressrelated behaviors,” naming the cluster PLST or secondary behavioral symptoms. They subsequently incorporated all four clusters into the PLST Model. In particular, the clusters form the basis of care planning within the model, in that they help caregivers to identify the symptoms that are present and to understand the care recipients’ current levels of function (Hall, 1998). Hall and Buckwalter (1987) assert that people with dementia present with several symptoms from each cluster throughout the course of their illness. Initially, these symptoms are generally mild; however, they become “worse and more constant with disease progression” (Hall, 1998, p. 76). The PLST Model hypothesizes, therefore, that each human being has a stress threshold that is more or less set in adulthood, and that any changes in the aforementioned four biological coping mechanisms can lower this stress threshold. This can be temporary, for example, when people develop cataracts that limit their ability to sense or perceive, or permanent, such as in brain damage or dementia. Hall and Buckwalter (1987) proposed that symptoms from the fourth cluster (decreased stress threshold) result from progressive loss of individuals’ ability to cope with stressors impinging upon them. When stress exceeds their threshold level, persons begin to exhibit secondary symptoms, most notably increasing anxiety, increased psychomotor behavior such as agitation and restlessness, and escape or avoidance behaviors such as wanting to leave. These, according to Hall and Buckwalter (1987), need to be recognized as evidence of increasing discomfort in the care recipients, and an attempt by them to avoid a dysfunctional episode or catastrophic response. Hall (1998, p. 80) indicates that such an episode “leads to one or more of the behaviors in the fourth cluster, . . . ” and that during such an episode “the care recipient becomes socially and cognitively inaccessible . . . . ” This means that during a dysfunctional episode, little communication or other forms of constructive engagement occur among the care recipients and those in their environment; that the care recipients are generally in fear during the episode; and that their ability to think and function is diminished. This sudden



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functional decline is referred to in the model as “excess disability.” Hall (1998) indicates that an episode such as this may immediately follow a stressful event, or may be delayed for a day or two. In addition, a vicious cycle of catastrophic or dysfunctional behaviors may become established if measures are not taken to address the causative stressors. The PLST Model proposes, therefore, that people with dementia have a diminished ability to receive, process, and respond to environmental stimuli, and that this is a direct result of the progressive deterioration in the cognitive, affective, and functional abilities that characterize dementia. The model further proposes that three types of behavior occur in people with dementia: (a) baseline or normative, (b) anxious, or (c) dysfunctional (Figure 9.1). These behaviors vary depending on people’s perceptions of environmental stimuli at any given time, as well as their stage of dementia. Baseline or normative behavior is where individuals are in a calm state and where they are functioning within the limits of their cognitive impairment. The person at baseline is both socially accessible (able to communicate needs and respond to others’ communication) and cognitively accessible (aware of and oriented to their environment). Baseline behaviors however “diminish with disease progression and are replaced by proportionately more anxious and dysfunctional behaviors” (Hall & Buckwalter, 1987, p. 401). In this state, environmental stimuli are seen to fall within the persons’ stress ­threshold; hence, they can cope and function adequately. Anxious behavior includes avoidance or escape behavior and occurs when people feel stressed or that they are losing control. Individuals lose eye contact with those around them and they attempt to avoid the offending stimuli; however, it is still possible for caregivers to make or maintain contact (Hall & Buckwalter, 1987). If the anxious behavior persists or the excessive environmental stimuli continue, it is likely that a person’s behavior can escalate to the next stage, dysfunctional behavior (Hall, 1998). This is characterized by verbal outbursts, fear or panic, wandering, night wakening, agitation, sudden withdrawal, or aggression. Effective communication breaks down and the person is no longer able to use the environment in a functionally appropriate manner (Hall & Buckwalter, 1987). This state is usually sudden in onset and generally short-lived. This particular observation is consistent with the stage of exhaustion in Selye’s (1980) General Adaptation Syndrome,

Figure 9.1  Effects of stress in a person with ADRD (Alzheimer’s disease or a related dementia) during a 24-hour day. Dysfunctional behavior

Stress threshold — Anxious behavior

AM

Noon

Source: Hall and Buckwalter (1987).

PM

Night

Normative behavior

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according to Hall (1998). The model posits that when the environmental stimuli abate or are adjusted or removed, functional behavior is likely to reappear (Hall & Buckwalter, 1987). Smith et al. (2004) propose that when persons exhibit anxiety, agitation, or avoidance behaviors, this indicates that they are at the limits of their stress threshold. Essentially, these symptoms represent a warning light to caregivers that people are about to cross their stress threshold. Thus, recognition and intervention at this juncture are crucial to preventing a dysfunctional episode. Ideally, intervention should occur before the person reaches a peak level of agitation in order to maximize effectiveness (Smith et al., 2004). Further explicating the model, Hall and Buckwalter (1987) identified six common stressors that may lead to a dysfunctional or catastrophic episode and hence to a sudden loss in functional ability: (a) fatigue; (b) change of environment, routine, or caregiver; (c) misleading stimuli or inappropriate stimulus levels; (d) affective responses to perceptions of loss, including anger and depression; (e) internal or external demands to achieve some goal that exceeds the person’s functional capacity; and (f) physical stressors such as pain, discomfort, infection, and acute illness producing concomitant delirium. Fatigue is seen as the most common stressor according to the model. A deteriorating brain must work very hard to process information from the environment; this mental effort expends a great deal of energy—hence, fatigue results. Hall (1998) asserts that these common stressors can be used to guide care planning, and can also operate as a quick assessment of causative stressors, when a dysfunctional episode or sudden functional loss has occurred. The PLST Model also hypothesizes a circadian pattern for the stress threshold, with the highest stress threshold occurring in the morning and the lowest in the evening (Figure 9.2). This notion is congruent with sundowning syndrome and with Hall and Buckwalter’s (1987) assertion that fatigue is the most common cause of stress for the person with dementia. It also agrees with Hall and Buckwalter’s clinical observations and temporal patterning of behaviors over a 24-hour period, which showed that a majority of people with dementia exhibit lower stress levels in the morning. However, stress may accumulate throughout the day, culminating in a breaching of the person’s stress threshold in the afternoon (Smith et al., 2004). One key recommendation of the model, therefore, is for caregivers to build frequent rest periods (every 90 minutes) into the care recipients’ daily routine in order to enable them to return to baseline (Figure 9.2).

Figure 9.2  Planned activity levels to maintain normative behavior for a person with ADRD (Alzheimer’s disease or a related dementia) during a 24-hour day. Dysfunctional behavior Stress threshold Anxious behavior

Normative behavior AM Source: Hall and Buckwalter (1987).

Noon

PM

Night



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RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS Whereas nursing metaparadigm concepts are not explicitly addressed in the PLST Model, the concepts of person, health, environment, and nursing can readily be related to the assumptions underpinning the model and its associated intervention. In the PLST Model, the concept of person not only relates to the person with dementia but also to the primary caregiver, usually a family member. This caregiver– care recipient dyad is seen as somewhat intertwined in that if care recipients become stressed, their behavior deteriorates, resulting in negative outcomes for both the person with dementia and the caregiver. Conversely, if the caregiver is able to manage these behaviors (such as through the application of PLST principles), outcomes for both members of the dyad are more favorable. Although health is not directly addressed in the PLST Model, health benefits to both caregiver and care recipient as a result of the application of PLST principles to care planning are evident from the literature. The PLST intervention aims to prevent and manage secondary dysfunctional behaviors of dementia that arise from environmental stress. It is well established in the literature that these behaviors are the greatest source of burden and distress for family caregivers (Michon, Weber, ­Rudhard-Thomazic, & Giannakopolous, 2005; Sörensen, Duberstein, Gill, & Pinquart, 2006), resulting in caregiver burden and depression (Tyrrell, 2012); a deterioration in the caregivers’ physical health (Pinquart & Sörensen, 2003a, 2003b); and even premature caregiver mortality (Schulz & Beach, 1999). Arguably, therefore, implementation of the PLST principles to care may confer health protection benefits to the caregiver. The PLST Model acknowledges that some of the secondary or problem behaviors of dementia result from the brain damage that occurs due to the dementing process; however, other behaviors result from environmental stress. In the model, therefore, caregivers are taught how to recognize and manage these environmental stresses in order to prevent or lessen the occurrence of these behaviors. According to the PLST, stressors result from factors in individuals’ external environment (e.g., multiple competing stimuli, misleading stimuli, change in caregiver or routine, and noise), as well as from factors in their internal environment (e.g., fatigue, hunger, thirst, pain, constipation, and side effects of medication). These environmental factors become the target for PLST interventions. Nursing is not explicitly mentioned in the PLST Model. The original PLST intervention was developed to enable informal dementia caregivers to understand, predict, prevent, and/or manage secondary dysfunctional behaviors of dementia. More recently, a need was recognized to implement PLST principles across the continuum of care because community-dwelling adults with dementia may occasionally have to be admitted to acute care or to long-term care (Smith, Hall, Gerdner, & Buckwalter, 2005). If formal dementia caregivers such as nurses in these care settings are unfamiliar with PLST care principles, then the benefits of home-based PLST care planning are likely to break down, resulting in deterioration in the care recipients’ behavior.

THEORY ANALYSIS In this section, the PLST is considered in the context of Fawcett’s evaluative criteria of significance, internal consistence, parsimony, testability, empirical adequacy, and pragmatic adequacy (Fawcett, 2005). Additional details are presented in Table 9.1.

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Table 9.1 Evaluative Criteria as Applied to the Use of the Progressively Lowered Stress Threshold (PLST) Model Questions for evaluation

1.

Responses to questions

Does the model fit the research that you wish to do?

The Progressively Lowered Stress Threshold (PLST) Model forms the basis for the PLST intervention that was developed to teach dementia caregivers how to understand, prevent, and manage stress in the environment of people with dementia. The model holds that stress is a significant factor in the genesis of secondary behaviors in dementia. Hence, this theory fits with the author’s study, the aim of which was to examine if adapting the PLST intervention for group delivery could reduce informal caregivers’ burden and their symptoms of depression.

2. Is it readily operationalized?

Yes, the model is readily operationalized in the intervention and is easy to teach to informal dementia caregivers because the core concepts address a simple issue: Stress is a significant cause of secondary behaviors in people with dementia, and in turn causes distress to their caregivers. By teaching caregivers to understand this idea, they can develop care plans to “de-stress” the environment in which the person with dementia lives, thus reducing the incidence of secondary behaviors and the negative effects these have on both the caregiver and the care recipient.

3. How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it relates?

The PLST intervention has been used with dementia caregivers in diverse contexts examining a variety of both caregiver and care recipient outcomes over the past 30 years. The PLST intervention has consistently been shown to produce positive outcomes for both caregiver and care recipient alike, with studies identifying improvements in the care recipients’ functioning (Gerdner, ­Buckwalter, & Reed, 2002) and behavior (Huang et al., 2003); improved caregiver self-efficacy (Huang et al., 2003; Swanson, Maas, & Buckwalter, 1993); greater caregiver self-confidence (Kelly, Buckwalter, Hall, Weaver, & Butcher, 2002); a reduction in caregiver depression (Buckwalter et al., 1999; Tyrrell, 2012) and burden (Stolley, Reed, & Buckwalter, 2002; Tyrrell, 2012); and improvements in caregivers’ immune functioning (Garand et al., 2002).

4. Does the theory relate to and address the research hypotheses in its description and explanation?

Yes, the main hypothesis set out to test if adapting the PLST intervention for group delivery could result in a decrease in caregivers’ burden and their symptoms of depression. The model helps explain the relationship between the intervention and the significant changes that occurred in these caregiver outcomes.

5. Does the theory flow from the research question?

Yes, the research question was logically derived from the PLST Model in that it set out to test a core assumption within the model: Teaching caregivers to apply the model in practice would result in less distress for them because it would enable them to prevent and manage stress in the environment of care recipients (stress being a key factor in the genesis of secondary behaviors in persons with dementia and in turn a major source of distress for caregivers). The model guided the development of the research question and the associated hypotheses. (continued )



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Table 9.1 Evaluative Criteria as Applied to the Use of the Progressively Lowered Stress Threshold (PLST) Model (continued ) Questions for evaluation

6. Does the theory address the primary and secondary research questions?

7.

Responses to questions

Yes, the primary research question was to examine if the adapted PLST intervention could have a positive impact on caregivers’ burden and their symptoms of depression. The secondary research question was to examine if certain caregiver characteristics could help explain any changes noted in these outcomes. The theory helps explain the outcomes stated in both the primary and secondary research questions.

Yes, the assumptions are congruent. The assumptions made for the Are the assumptions congruent with the assumptions research are that environmental stress is a significant factor in the that are made for research? genesis of secondary behaviors in dementia and that these behaviors have a negative impact on the caregiver. They have been shown to be the greatest source of distress among informal dementia caregivers. Teaching caregivers to understand, predict, prevent, and manage stress in the environment of persons with dementia should result in less of these negative behaviors and, hence, less distress (such as burden and depression) among caregivers.

8. Is the theory oriented to outcomes that are critical to patients?

Yes, the outcomes that have been shown to be positively influenced by the PLST intervention are critical to the health and well-being of the caregiver and care recipient alike.

9. Are tools available to test relationships of the theory or do they need to be developed?

Yes, in the author’s study, the Zarit Burden Interview (ZBI) and the Center for Epidemiological Studies Depression (CES-D) scale were used to test the relationship between receiving the PLST intervention and improvements in caregivers’ burden and their symptoms of depression, respectively. A variety of other tools have been used in previous PLST research.

Source: Fawcett (1999, 2005).

Many informal dementia caregivers derive personal satisfaction from fulfilling the caregiving role (Cohen, Colantonio, & Vernich, 2002), and most aspire to maintain the care recipient in the home environment for as long as possible because this is the place where most older adults wish to reside (O’Shea, 2007). Caregiving for a person with dementia can be a stressful endeavor, however, with significant negative consequences for both the caregiver and care recipient alike. Informal dementia caregivers who are constantly exposed to dysfunctional behaviors in care recipients are at risk of becoming burdened and depressed (Tyrrell, 2012), and may suffer poor physical health as a result (Pinquart & Sörensen, 2003a, 2003b). Burdened caregivers are more likely to resort to early institutionalization of the person with dementia; however, institutional care is expensive and may lead to deterioration in the patient’s quality of life. Paradoxically, it may also lead to increased burden for the caregiver (Gaugler, Roth, Haley, & Mittelman, 2008). Caregivers who are supported, however, and who are taught interventions such as the PLST that can offset these negative behaviors are more likely to be able to cope and, hence, to continue caregiving for longer. This evidence-based intervention can therefore be seen to contribute significantly to the health and welfare of people with dementia and that of their caregivers. The PLST intervention was originally developed for a nonprofessional audience. Hall and Buckwalter, in developing the model, ensured that the language used to

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describe the underlying assumptions and concepts of the model was accessible to this audience. Hence, the core concepts and their interrelationships with each other are easy to understand. Core concepts of the model have been both operationally and theoretically defined; however, some of the language used in the associated research papers is not readily accessible to a lay audience (e.g., excess disability, dysfunctional behaviors, and prosthetic device). The PLST Model deals with some complex concepts and processes associated with the genesis of problem behaviors in dementia. Many of the biological and psychosocial theories that influenced Hall and Buckwalter in the development of the PLST are complex in themselves. Nevertheless, Hall and Buckwalter succeed in synthesizing this complexity into what is essentially a simple central idea: Many of the behaviors of dementia are stress-related; different stresses operate in dementia. This is important because the intervention based on the model was designed for a nonprofessional audience: informal dementia caregivers. Accordingly, Hall and Buckwalter achieve the criterion of parsimony in their description of the model. The PLST intervention has been tested empirically—up to and including randomized controlled trial (RCT) level—in a variety of contexts, and has been shown to confer benefits to both the caregiver and care recipient as outlined earlier in this chapter. A variety of outcome measures have been used to this end. In the main, these have been measured using established and evidence-based instruments; however, some critiques of chosen instruments exist (Tyrrell, 2012). The empirical adequacy of the PLST intervention has been established. In addition to single studies, a number of multisite studies of the intervention have also been conducted; these have utilized a variety of quasi-experimental and experimental designs, including RCTs. Moreover, the majority of the studies conducted on the PLST have supported the assumptions of the model. The PLST intervention has also been accorded evidence-based treatment status (Gallagher-Thompson & Coon, 2007; Logsdon, McCurry, & Teri, 2007). The pragmatic adequacy of the PLST intervention is apparent from the studies conducted. The care principles of the PLST intervention are easily understood, and can readily be applied to both informal dementia caregiving in the home and to nursing practice in a variety of contexts, as detailed by Smith et al. (2005). It operates around the simple concept that many behaviors associated with dementia are stress-related; hence, if one predicts, prevents, and/or manages these environmental stressors, fewer negative outcomes are likely to occur with consequent benefit to the caregiver and care recipient alike. Informal dementia caregivers can easily understand the assumptions underpinning the intervention and find them logical and easy to implement in practice (Tyrrell, 2012).

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING The PLST Model was originally developed by Hall and Buckwalter in 1985 and evolved from an understanding of behaviors of persons with dementia in the context of theories of person–environment fit/interaction (Wolanin & Phillips, 1981). These theories are useful in “designing environmental interventions that focus on restitution, compensation, and accommodation of impaired functions and dysfunctional behaviors” (Buckwalter, Hall, Kelly, Sime, & Richards, 1997, p. 3). Accordingly, the PLST Model has been used to guide interventions for persons with ADRD and



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emphasizes the importance of family (and professional) caregivers, as well as their relationships in the care recipients’ environment. Hence, researchers have used the PLST Model as a framework for education and skills programs as psychoeducational interventions in both community and institutional settings. A number of studies of the PLST intervention have been carried out over the past 20 years. In general, positive changes have been found in favor of the intervention for a variety of caregiver, care recipient, and dementia staff outcomes. Gerdner, Buckwalter, and Reed (2002), for example, examined the effect of the PLST on the caregivers’ response to the care recipients’ behavior and on their degree of functional decline. They found that the effect of the PLST varied in accordance with the caregiver’s relationship to the care recipient (spouse or nonspouse). Huang et al. (2003) examined its effect on caregivers’ self-efficacy and on the care recipients’ manifestation of behavioral problems, finding that caregivers who received the PLST intervention had a significant increase in their self-efficacy; in addition, many care recipient behaviors improved. Similarly, Kelly, Buckwalter, Hall, Weaver, and Butcher (2002) found that the intervention led to greater caregiver self-confidence in their role and greater confidence in the adequacy of their caregiving efforts. Moreover, Swanson, Maas, and Buckwalter’s (1993) study of the intervention found that there was a significant reduction in problem behaviors in patients in a special dementia unit run along the lines of the PLST principles. In addition to these studies, other PLST studies have focused on burden and depression as caregiver outcomes. Once more, in general, results have endorsed this intervention as one that is worthwhile in assisting caregivers in their role. One of the foremost community-based studies was that by Buckwalter et al. (1999). In a 4-year longitudinal study conducted across four U.S. states, they evaluated the effectiveness of a ­community-based psychoeducational nursing intervention based on the PLST Model that was used to teach informal caregivers in the home how to manage behavioral problems of dementia patients. Subjects in the experimental group (N = 132) received this training, whereas subjects in the control group (N = 108) received routine information only on dementia. Subjects were randomly assigned to either group. The primary aim of the study was to evaluate the effectiveness of the PLST-based program on caregivers’ affective responses to caring, chiefly, their levels of depression. ­Initial individual interviews were held with subjects from both groups, during which baseline data were collected on mood and depression ratings using the Profile of Mood States (POMS) (McNair, Lorr, & Droppleman, 1971), and the Geriatric Depression Rating Scale (GDRS) (­Yesavage et al., 1983). At these initial interviews, subjects in the control group were introduced to the PLST Model; in addition, individualized care plans, tailored to the needs of the dementia patients they cared for, were developed. Subjects were taught how to use the care plans as intervention strategies to assist them in caring for the specific challenging behaviors exhibited by the relatives they looked after. Within 2 weeks, researchers again met with the experimental group subjects in their own homes; the PLST-based care plans were further rehearsed utilizing examples, with the subjects being assessed on how to apply the care plans in order for the researchers to determine their competence. Second in-home visits took place with experimental group subjects 1 week later. Further practice in implementing the care plans took place at these visits, and additional written guidelines summarizing the care plans were given to subjects. In total, experimental group subjects received between 3 and 4 hours of in-home tuition on the PLST intervention after the initial baseline assessment.

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In addition, these subjects received biweekly follow-up support phone calls from a researcher for 6 months. Subjects in the control group also received two in-home visits after baseline assessment. These were of similar duration and were also spaced 2 weeks apart. These subjects, however, received general information only about Alzheimer’s disease and referral to community-based services and support groups. In addition, control group subjects received a copy of the textbook The 36-Hour Day (Mace & Rabins, 1991), a generic dementia caregiver book. They participated in the same follow-up support phone calls and had data-collection protocol identical to the experimental group subjects. Findings indicated a significant reduction in depression at 6 months (as measured by the POMS) in caregivers who received the training based on the PLST Model when compared to those who received routine information only. However, at 12 months, this improvement was no longer statistically significant. Findings from the analysis of the second depression measure used (the GDRS) were more promising at both 6 months and 12 months; intervention group subjects were less depressed than those in the comparison group, and this reached statistical significance. However, data from a subgroup of younger caregivers indicated a trend toward increased depression over time. These findings correspond with those of Cruz (1997) who, in a correlational study using a subset of the data from the Effectiveness for Rural ADRD Caregivers Study, examined the impact of the PLST intervention on predictors of depression among informal dementia caregivers. A further aim was to investigate the longitudinal effects of the intervention on changes in predictors of depression. Subjects were allocated to a PLST intervention group or a comparison group and analysis revealed that subjective burden and being a caregiving spouse were the most reliable predictors of caregiver depression, accounting for 27% of the variance. Although both groups were found to have significant increases in burden over time (baseline to 12 months), these increases were greater for comparison group caregivers. In addition, no statistically significant differences were found between groups on depression scores at 12 months. There was a significant difference within groups across time, with the comparison group reporting greater increases in depression. In a further paper relating to the Effectiveness for Rural ADRD Caregivers Study, Stolley, Reed, and Buckwalter (2002) measured the impact of a psychoeducational program based on the PLST Model on caregiving appraisal. Caregiving appraisal was measured using the relevant sections (four) of the Philadelphia Geriatric Center Caregiving Appraisal Scale (PGCCA) and included items on burden, mastery, satisfaction, and impact. This year-long multisite study reported on data from 241 subjects who enrolled in the study, 133 of whom were randomly assigned to the experimental group and the remainder to the control group. In this study, the same PLST intervention as that reported earlier by Buckwalter et al. (1997, 1999) was used. The results of this quasi-experiment showed that, over time, data from subjects in the experimental group demonstrated that the PLST intervention positively affected impact, burden, and satisfaction, but not mastery, when compared to those in the control group. Researchers have also examined the effectiveness of the PLST Model in determining positive changes in patients’ physical as well as mental health. Garand et al. (2002), for example, undertook a pilot study of immune and mood outcomes in a communitybased intervention for dementia caregivers based on the PLST Model. These mood and immunity outcomes were compared among caregivers who were randomly assigned to receive the PLST-based intervention psychoeducational program (experimental group; N = 39) or a comparison intervention (control group; N = 39). Subjects in



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the experimental group showed a significant improvement in T-cell immune function immediately after the intervention, as well as after 6 months of telephone support on application of the PLST Model to their caregiving situations. No significant improvement in mood outcomes was found in the intervention group, however.

USE OF THE THEORY IN THIS RESEARCH In 2012, Tyrrell undertook a study of the PLST intervention among a group of informal dementia caregivers (N = 128) in Ireland. The original PLST intervention (outlined earlier in this chapter) was delivered to caregivers on a one-to-one basis in the caregivers’ homes. However, Tyrrell (2012) proposed that delivering the intervention to groups of caregivers might be as effective as delivering it in the traditional one-toone mode, and that it was more efficient to deliver it to groups of caregivers together because it allowed the intervention to be delivered to a greater audience of caregivers in the same time frame. To this end, Tyrrell (2012) adapted the original PLST intervention for group delivery.

The Group PLST Intervention The group PLST intervention is based on the same essential elements as the PLST Model featured in the original intervention. In common with the original intervention, baseline measures on the study outcomes are taken at the first session, followed by an introduction to the core features of the PLST Model. Caregivers are then introduced to the principles of care planning using the PLST Model; however, unlike in the original intervention, this is based on the Standardized Care Plan that was developed and published by Hall et al. (1995), and on the PLST care plans presented by Smith et al. (2005). These were both developed after the original intervention was published and are based on the PLST Model. They also focus on common care recipient problems or caregiver challenges that occur, particularly in the context of PLST behaviors. Essentially, the care planning component of the group intervention addresses the same care planning issues as the original intervention but not on a one-to-one basis. In subsequent sessions of the group intervention, further material on the PLST Model is presented and discussed; this material is then applied to care planning— again based on the Standardized Care Plan (Hall et al., 1995; Smith et al., 2005). Throughout the three group intervention sessions, participating caregivers are given a series of information leaflets based on the PLST that address a variety of care issues (Hall, 2008). They are also asked to complete three worksheets (one after each of the three sessions), the aim of which is to assess their ability to apply the principles of PLST to their caregiving situations. In addition to the above and in common with the original intervention, caregivers receive biweekly check-in telephone calls from an interventionist for 13 weeks.

Comparing the Original and Group Formats of the PLST Intervention The original PLST intervention is essentially the same in content and focus as the group PLST intervention. Like the original PLST intervention, the group PLST intervention was developed along the principles of the PLST Model. The same PLST information is presented and examined, and care plans are developed addressing the same

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issues, but this is done in a group format. Behavioral Assessment for Low Stimulus Care Plan (BALSCP), therefore, is not used because this instrument is specifically designed for individual care plan development. There are other differences as well; for example, the original protocol used the POMS and the GDRS to measure caregiver depression, and used the PGCCA to measure caregiver burden. The POMS only showed partial effectiveness in the original studies. Also, the GDRS is specifically designed to measure depression in older informal dementia caregivers; however, not all informal dementia caregivers are older. For these reasons, Tyrrell (2012) chose to use the CES-D (Center for Epidemiological Studies Depression) scale. The CES-D scale measures symptoms of depression rather than clinical depression (although it also can detect the latter). Measuring symptoms of depression among informal dementia caregivers is important because these contribute significantly to caregiver morbidity and may not be captured using clinical diagnostic assessments. Similarly, the PGCCA is not a specific measure of burden because it also measures caregiver appraisal, satisfaction, perceived impact, and mastery (as well as burden). The ZBI (Zarit Burden Interview), on the other hand, is designed specifically to measure caregiver burden.

Testing the Group PLST Intervention The aim of Tyrrell’s (2012) study was to establish if a group intervention based on the PLST had a beneficial effect on informal dementia caregivers’ burden and their symptoms of depression. The intervention was an adaptation of Hall and B ­ uckwalter’s PLST intervention for group delivery, and was delivered to 13 groups of caregivers, from both rural and urban areas in the Republic of Ireland, ranging in size from 8 to 12 caregivers per group. Caregiver burden was measured using the ZBI (Zarit & Zarit, 1987), and caregiver symptoms of depression were measured using the CES-D scale (Radloff, 1977). Caregiver demographic data were measured using a researcherdeveloped questionnaire. Informal dementia caregivers (128) were recruited and consented to participate in the study. Results showed a statistically significant decrease in both burden and depression scores after the intervention, and that the decrease in depression scores persisted over time. A key conclusion drawn by Tyrrell (2012) was that adapting the original PLST intervention for group delivery can reduce informal dementia caregivers’ levels of burden and their symptoms of depression.

RECOMMENDATIONS FOR FURTHER RESEARCH The findings of the research conducted to date on the PLST intervention provide a basis for future research to further develop and test the PLST intervention in both individual and group formats—not only with informal dementia caregivers but also with formal dementia caregivers in a variety of settings and contexts. In particular, a comparison study of both formats of the intervention should be conducted with a larger and more representative sample of informal dementia caregivers. The efficacy and cost effectiveness of both the original PLST intervention and the group PLST intervention should be examined through further research, and a comparative cost analysis between these two formats of the intervention should be undertaken. This cost analysis should also include an evaluation of the cost to the government should the caregiver have to cease caregiving as a result of outcomes such as burden and depression.



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Evidence from the literature recommends that future research examine which interventions work for which types of caregivers under what conditions. It is suggested, therefore, that future RCTs of the original and group PLST interventions focus on diverse groups of caregivers (spouses, adult-child caregivers, and nonrelated caregivers) in different circumstances (care recipients in different stages of dementia and different types of dementia). One of the difficulties identified in the literature in conducting caregiver research is that many caregivers cannot take regular time off from caregiving to attend support groups or intervention groups. This is primarily because of the difficulties in getting someone to take over caregiving for that period, and the fact that some caregivers, especially those in rural locations, do not have ready access to transport. The literature shows a growing interest in technology-based interventions, and early results for some of these interventions are promising. Given the increasing penetration levels of broadband, and the relatively high levels of home computer ownership in the Western world, it is recommended that research be conducted on the efficacy and effectiveness of the PLST intervention as delivered over the Internet in virtual group format.

SUMMARY The PLST Model proposes that a person has a stress threshold that is firmly established by adulthood; however, this can be temporarily altered during times of illness or permanently altered during episodes of brain damage, as is the case in dementia. Normally, adults have a relatively high threshold to stress. People with dementia have a diminished ability to interact with their environment. They find things in their environment confusing because their brains are no longer able to process information accurately. Consequently, they have a heightened potential for anxiety and dysfunctional behavior—their stress threshold is lower (Hall & Buckwalter, 1987). The model posits that “persons with dementia need environmental conditions modified as they experience progressive cognitive decline so that cues can be more easily processed and are thus less stressful” (Smith et al., 2004, p. 1756). The principles underpinning the PLST Model have been adapted to form the PLST intervention for informal caregivers, the main focus of which is on the caregiver modifying the home environment to accommodate the care recipient’s diminishing stress threshold (Smith et al., 2005). Some of the key stressors identified by the model are fatigue; multiple competing stimuli or too many things going on at once (e.g., eating dinner, receiving medications, background music playing, and visitors calling all at the same time); illness; side effects of medicines; and changes in caregiver, routine, or environment (Smith et al., 2004, 2005). The model recommends that caregivers establish simple routines and adhere to them, that they assess stressors in individuals’ environments on an ongoing basis, and that they eliminate or modify these in order to make the world appear less stressful. The key warning signs that people with dementia are reaching their stress threshold are anxiety, agitation, and avoidance or escape behaviors. If these occur, the recommendation is that caregivers take immediate action to reduce the stress by promoting rest; decreasing stimuli (i.e., noise, too many people present, television or radio playing); and assessing for and eliminating internal stressors such as hunger, pain, or constipation. The PLST intervention has been shown to have significant benefits for people with dementia and their family caregivers. Among the

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findings are studies that have shown improvements in the behaviors of people with dementia (Gerdner et al., 2002); a reduction in caregiver depression (Buckwalter et al., 1999); decreased caregiver burden and increased satisfaction (Stolley et al., 2002); and improvements in immune functioning (Garand et al., 2002). More recently, Tyrrell (2012) adapted the intervention for group delivery and found that a group PLST intervention could produce significant reductions in caregivers’ burden and their symptoms of depression. In 2007, the intervention was granted evidence-based treatment status (Gallagher-Thompson & Coon, 2007; ­Logsdon et al., 2007). Although the PLST Model was not developed as a nursing theory per se—and hence the nursing metaparadigm concepts are not explicit in the model—a core concept of the model is that the environment is a significant source of stress for individuals with dementia and that this stress may result in a deterioration in the health and well-being of people with dementia and their caregivers. Thus, it is possible to relate the PLST Model and its associated intervention to these metaparadigm concepts. In addition, an application of Fawcett’s (2005) evaluative criteria for nursing theory demonstrates that the PLST Model fulfills the core criteria of significance, internal consistency, parsimony, testability, empirical adequacy, and pragmatic adequacy. Further research might focus on a cost analysis of the PLST intervention in both formats, as well as a comparative evaluation of these formats in terms of their ability to produce positive outcomes for the care recipient and caregiver.

References Buckwalter, K. C., Gerdner, L., Kohout, F., Hall, G. R., Kelly, A., Richards, B., & Sime, M. (1999). A nursing intervention to decrease depression in family caregivers of persons with ­dementia. Archives of Psychiatric Nursing, 13, 80–88. Buckwalter, K. C., Hall, G. R., Kelly, A., Sime, M., & Richards, B. (1997). PLST Model: Effectiveness for rural caregivers (Final Report No. R01-NR03434). University of Iowa, Iowa City. Cohen, C. A., Colantonio, A., & Vernich, L. (2002). Positive aspects of caregiving: Rounding out the caregiver experience. International Journal of Geriatric Psychiatry, 17(2), 184–188. Cruz, V. (1997). PLST Model-based intervention: Impact on predictors of depression among ADRD family caregivers (Unpublished PhD thesis). University of Iowa, Iowa City. Fawcett, J. (1999). The relationship of theory and research. Philadelphia, PA: F.A. Davis. Fawcett, J. (2005). Criteria for evaluation of theory. Nursing Science Quarterly, 18, 131–135. Gallagher-Thompson, D., & Coon, D. W. (2007). Evidence-based psychological treatments for distress in family caregivers of older adults. Psychology and Ageing, 22(1), 37–51. Garand, L., Buckwalter, K. C., Lubaroff, D. M., Tripp-Reimer, T., Frantz, R. A., & Ansley, T. N. (2002). A pilot study of immune and mood outcomes of a community-based intervention for dementia caregivers: The PLST intervention. Archives of Psychiatric Nursing, 16(4), 156–167. Gaugler, J. E., Roth, D. L., Haley, W. E., & Mittelman, M. S. (2008). Can counselling and support reduce burden and depressive symptoms in caregivers of people with Alzheimer’s disease during the transition to institutionalization? Results from the New York University caregiver intervention study. Journal of the American Geriatrics Society, 56, 421–428. Gerdner, L. A., Buckwalter, K. C., & Reed, D. (2002). Impact of a psychoeducational intervention on caregiver response to behavioral problems. Nursing Research, 51, 363–374. Hall, G. R. (1998). Testing the PLST with community based caregivers (Unpublished PhD dissertation). University of Iowa, Iowa City.



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Hall, G. R. (2008). Banner Alzheimer’s institute memory assistance and planning services: Module 1–Introduction to memory loss & Module 2: Stages of Alzheimer-type dementias. Phoenix, AZ: Banner Health Institute. Hall, G., & Buckwalter, K. (1987). Progressively Lowered Stress Threshold: A conceptual model for care of adults with Alzheimer’s disease. Archives of Psychiatric Nursing, 1(6), 399–406. Hall, G., Buckwalter, K., Stolley, J., Gerdner, L., Garand, L., Ridgeway, S., & Crump, S. (1995). Standardized care plan: Managing Alzheimer’s patients at home. Journal of Gerontological Nursing, 21(1) 37–49. Huang, H., Shyu, Y. L., Chen, M., Chen, S., & Lin, L. (2003). A pilot study on a home-based caregiver training program for improving caregiver self-efficacy and decreasing the behavioral problems of elders with dementia in Taiwan. International Journal of Geriatric Psychiatry, 18, 337–345. Kahana, E. (1975). A congruence model of person-environment interaction. In P. Windley, T. Byerts, & F. Ernst (Eds.), Theory development in environment and aging (pp. 181–214). Washington, DC: Gerontological Society. Kelly, A. W., Buckwalter, K. C., Hall, G., Weaver, A. L., & Butcher, H. (2002). The caregiver’s story: Home caregiving for persons with dementia. Home Health Care Management and Practice, 14(2), 99–109. Kovach, C. (2000). Sensoristasis and imbalance in persons with dementia. Journal of Nursing Scholarship, 32, 379–384. Lawton, M. (1975). Competence, environmental press and the adaptation of older people. In P. Windley, T. Byerts, & F. Ernst (Eds.), Theory development in environment and aging (pp. 13–88). Washington, DC: Gerontological Society. Lawton, M. P. (1986). Environment and aging (2nd ed.). Albany, NY: Center for the Study of Aging. Lawton, M., & Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer & M. Lawton (Eds.), Psychology of adult development and aging (pp. 619–674). Washington, DC: American Press. Lazarus, R. S. (1966). Psychological stress and the coping process. New York, NY: McGraw-Hill. Lewin, K. (1951). Field theory in social science: Selected theoretical papers. New York, NY: Harper and Row. Logsdon, R. G., McCurry, S. M., & Teri, L. (2007). Evidence-based psychological treatments for disruptive behaviors in individuals with dementia. Psychology and Aging, 22(1), 28–36. Mace, N. L., & Rabins, P. V. (1991). The 36-hour day. Baltimore, MD: Johns Hopkins University Press. Maletta, G. J. (1992). Treatment of behavioral symptomatology of Alzheimer’s disease, with emphasis on aggression: Current clinical approaches. International Psychogeriatrics, 4(3), 117–130. McNair, D. M., Lorr, M., & Droppleman, L. (1971). Manual for the profile of mood states. San Diego, CA: Educational and Industrial Testing Service. Michon, A., Weber, K., Rudhard-Thomazic, V., & Giannakopolous, P. (2005). Dynamic process of family burden in dementia caregiving: A new field of psychotherapeutic interventions. Psychogeriatrics, 5, 48–54. O’Shea, E. (2007). Implementing policy for dementia care in Ireland. Galway: National University of Ireland. Pinquart, M., & Sörensen, S. (2003a). Associations of stressors and uplifts of caregiving with caregiver burden and depressive mood: A meta-analysis. Journal of Gerontology ­Psychological Sciences, 58B, P112–P128.

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chapter 10

Cultural Competence Model Karen Bauce

In the 1990s, Schim and Miller were part of a collaborative research project designed to better understand the culture care needs of the Arab American community in an urban Midwestern area (Kulwicki, Miller, & Schim, 2000). At the time, Schim was a nurse scholar in the Center for Academic Nursing at the Henry Ford Health System in Detroit, Michigan, and Miller was a faculty member at the School of ­Nursing, ­Oakland University in Oakland County, Michigan. In partnership with the local health care system, the school of nursing, and the Arab American community, Schim and Miller sought to find common language for understanding the concepts of cultural competency and culturally competent care. Challenged by the inconsistent definitions of cultural competence and its related terminologies in extant theories and frameworks, Schim and Miller (1999) developed the Cultural Competence Model (CCM) as a beginning foundation for conceptualizing and measuring culturally competent practice by health care providers.

BASIC DESCRIPTION OF THE THEORY Hardy (2009) describes models as “a simplified representation of a theory or of certain complex events, structures, or systems” (p. 505). Models provide a means of visualizing critical aspects of a phenomenon of interest and the relationships among core concepts. In its current evolution (Schim, Doorenbos, Benkert, & Miller, 2007), the CCM uses the analogy of a three-dimensional (3-D) jigsaw puzzle to represent the four pieces, or constructs, of provider level competence: cultural diversity, cultural awareness, cultural sensitivity, and cultural competence behaviors. One of the main ideas of the model is that culturally congruent care is possible when there is an appropriate interconnecting of all four puzzle pieces by providers. Thus, providers who incorporate personal cultural diversity experience and cultural awareness and sensitivity into their practice behaviors demonstrate cultural competence (Schim, Doorenbos, Miller, & Benkert, 2003).

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CORE CONCEPTS Cultural diversity represents one’s personal exposure and experience with individuals from different groups. It encompasses differences in race and ethnicity as well as differences in language, religion, gender, sexual orientation, and socioeconomic class. Personal diversity experience varies according to the number of different groups encountered and the length and type of interaction. Cultural awareness refers to the knowledge of areas that may be a source of differences between and within groups. A culturally aware provider understands that culture can inform health care practices, preferences, and behaviors. This cultural awareness or knowledge about group variations facilitates the provider’s ability to more accurately assess individual and family needs and preferences for care. Cultural sensitivity reflects an individual’s attitude about oneself and others and a willingness to learn about people from different cultures. A culturally sensitive provider possesses an attitude of humility and seeks to gain knowledge and understanding about individual and family cultural expectations for care. Cultural sensitivity also requires understanding one’s personal, professional, and practice culture. Cultural competence involves a set of behaviors demonstrated in response to cultural diversity, awareness, and sensitivity. Cultural competence behaviors include assessing cultural preferences and adapting services to meet these preferences. ­Cultural competence varies at any given time depending on the provider’s diversity experiences, level of cultural awareness and sensitivity, and skills gained from previous interactions with patients and families. In Schim and Miller’s (1999) original conceptualization of provider level cultural competence, stair steps were used to illustrate the relationship among the four constructs. Cultural diversity was depicted as the bottom step, and cultural competence was the top step. Revisions to the model were made over time as the authors further clarified the constructs and their interrelationships. The jigsaw puzzle model evolved into a graphic representation of the interconnected and nonlinear relationship among the four components. Schim and colleagues (2007) theorize that all four constructs are required, but not individually sufficient, to achieve culturally competent care. The development of cultural competence is viewed as an ongoing process that is informed by each encounter with patients and families. The goal is not complete mastery of cultural competence but rather matching provider competencies to meet the needs of specific populations and individuals who are the recipients of care (Schim et al., 2007). The assumptions and propositions developed by Schim and colleagues (2007) to describe culturally congruent care and the relationships among the core concepts are listed verbatim below: Assumptions 1. The desired outcome, culturally congruent care, must be evaluated from the ­perspectives of the recipients and the providers of care. 2. Specific competencies (cognitive, affective, and psychomotor behaviors) can be defined, learned, and identified in practice. 3. The scope of competence is related to the number and variety of diverse groups and people encountered in community, social, and/or service contexts.



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4. The depth of competence is related to the amount of exposure and type of interaction with particular groups and people encountered in community, social, and/ or service contexts. Propositions 1. Culturally congruent care, with diverse persons and groups, representing a community of service at a given place and time, is necessary for health service quality. 2. Culturally competent behaviors on the part of providers are necessary but not sufficient to produce culturally congruent care. (p. 108) The first two assumptions describe basic premises about culturally congruent care. Inferred from the first assumption is that clients and providers equally contribute to the outcome of culturally congruent care. The last two assumptions reflect the relationship between two of the model concepts (cultural competence and diversity experience), which is more characteristic of propositional statements. Both model propositions are relational statements that identify associational relationships; these indicate that two concepts are related in a positive, negative, or unknown way (Walker & Avant, 2005). Culturally congruent care is positively associated with quality health service, but providers’ culturally competent behaviors do not always result in culturally congruent care. Schim and colleagues (2007) acknowledge that the client level of cultural competence requires development and articulation.

RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS THEORY The CCM is the only theoretical framework of cultural competence that informed the development of an assessment instrument for use by healthcare providers and staff with diverse roles, education, and backgrounds (Doorenbos, Schim, Benkert, & Borse, 2005). Yet, multidisciplinary research using the Cultural Competence Assessment (CCA) instrument remains limited. Krentzman and Townsend (2008) evaluated extant multidisciplinary measures of cultural competence for potential use in social work education based on the following criteria: validity, reliability, relevance to social justice, item clarity, definition of diversity, coherence, social desirability, and appropriateness for social work. The authors did not recommend the CCA as a potential research tool to measure cultural competence in social workers, partly because of a concern with potential socially desirable responding as well as the absence of items addressing social justice (Krentzman & Townsend, 2008). In the only published study found, the CCA was used to assess cultural competence among certified athletic trainers in the delivery of health services to patients and athletes (Marra, Covassin, Shingles, Canady, & Mackowiak, 2010). Study results indicated that self-reported cultural competence scores of athletic trainers were higher than their CCA scores. In addition, female ­athletic trainers were more culturally competent than male athletic trainers, and multiracial and African American athletic trainers were the most culturally competent. Athletic trainers with previous diversity training scored higher on the CCA than those without training, consistent with the positive correlation between prior diversity training and cultural competence behaviors in nurses (Schim, Doorenbos, & Borse, 2006a).

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RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS Fawcett (1985) defined a metaparadigm as a “global statement that identifies the domain of a discipline” (p. 226) and proposed that person, environment, health, and nursing constituted nursing’s metaparadigm. Explicit in nursing grand theories and inferred in middle range theories is the theorist’s interpretation of these four concepts. Schim and colleagues (2007) have described culturally congruent care as a “function of the complex and dynamic interface of providers and recipients of care under specific circumstances and at specific times” (p. 105), suggesting that human beings and environment are the major nursing metaparadigm concepts of interest. Human being refers both to the nurse and the recipient of care, which can include not only individuals but families, groups, and communities (Whall, 2005). Human beings in the CCM are represented by the provider level and client level of culturally congruent care, although the theoretical framework for the client level has yet to be articulated. Consistent with (Leininger & McFarland, 2002) belief that humans are cultural beings inseparable from their cultural background, the human being as provider of care has a unique cultural heritage and perspective that informs every interaction with the recipient of care. In addition, the recipient or client of care responds to the provider from the perspective of his own cultural identity and experience. “Each individual, family, and community represents a unique blend of overlapping and intersecting cultural elements in which the whole is greater than the sum of the parts” (Schim et al., 2007, p. 104). Human beings as providers are seen as capable of acquiring the cognitive, attitudinal, and behavioral competencies required to provide culturally competent care through an ongoing process of self-reflection, practicing new skills, and learning from each experience (Schim et al., 2007). Thus, in a dynamic process, human beings (i.e., providers of care), are continually striving to become culturally competent and may have varying degrees of competence in any given situation. The concept of environment in the CCM encompasses the myriad internal and ­external factors that contribute to the cultural context of human beings. “Cultures are constantly evolving in response to new environments and ever-changing physical, social, economic, and political realities” (Schim et al., 2007, p. 104). Similar to the role of environment in (Leininger & McFarland, 2002) the Theory of Cultural Care Diversity and ­Universality, environment in the CCM refers to a multifaceted dimension that has a pervasive influence on everything human beings experience and how they behave. Schim and colleagues (2007) believe that “the ways in which people experience and interpret the world are largely determined by the cultural contexts they inhabit” (p. 104). The concept of nursing is implicit in the CCM but difficult to discern. The model refers to effective interaction between health care providers and clients but does not elaborate on nursing-specific knowledge and practices that contribute to an effective outcome. Schim and colleagues (2006a) refer to the cultural humility and respect that nurses must possess; they state: “Nurses need to appreciate, accommodate, and negotiate cultural and individual variation in beliefs, values, lifestyles, education, and myriad other elements that cultural context comprises” (p. 303.) It can be inferred from this statement that the culturally competent nurse utilizes the nursing process to conduct cultural assessments, predict care needs, and plan and provide culturally congruent care that meets the diverse needs of patients and families. Schim (2005) explicitly refers to nursing when she asserts that, “Our professional



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culture in nursing encourages sensitivity and awareness of the need to advocate at the aggregate level while assessing and intervening with individuals and specific communities” (p. 256). Thus, implicit in the CCM is nursing as it relates to valuing and working with patient and family values, including their cultural traditions. Dreher and M ­ acNaughton (2002) argue that cultural competence is really nursing competence because it reflects the nurse’s ability to be equally therapeutic with patients regardless of social context or cultural background. Schim and colleagues (2007) might agree with Dreher and MacNaughton (2002) that cultural information is embedded in the illness experiences of all patients, not just those seen as “ethnic,” and failed patient–­provider communication, rather than cultural barriers, is responsible for the inability to individualize patient care. Also implicit in the CCM, but not defined, is the concept of health. One of the model’s propositions is that culturally congruent care is necessary for quality health care, given cultural influences on perceptions and experiences of health and illness. In addition, it can be inferred that culturally congruent care will result in better health outcomes for clients.

THEORY ANALYSIS Theories explain relationships between concepts to inform understanding of specific phenomenon of interest (Higgins & Moore, 2009). Fawcett (1985) states that, “The theories of a professional discipline are meaningless unless their utility as directives for practice has been established” (p. 228). Fawcett (2009) argues that theories must be evaluated for pragmatic adequacy and defines empirically testable theories as those that are “composed of concepts that are narrowly bounded, specific and explicitly interrelated” (p. 29). One of Fawcett’s (2005) criteria for evaluating nursing theory addresses whether the theory fits the area of interest for the desired research. The CCM articulates constructs of cultural competence in health care providers and thus fit this research study, which investigated the relationship between cultural competence and psychological empowerment among acute care nurses. Cultural competence is a phenomenon of interest shared by many disciplines, yet remains an important organizing construct for guiding nursing practice and in developing nursing knowledge (Dreher & MacNaughton, 2002). While the constructs articulated in the CCM were theorized as necessary elements of cultural competence for all health care providers, the CCM reflects nursing’s disciplinary perspective related to health and caring, as well as human– environment interaction. A second criterion concerns an analysis of adequacy, or the ability to develop and test operational definitions of model concepts that are consistent with theoretical definitions (Hardy, 2009). Whall (2005) describes middle range theories as being especially useful for nursing research because they contain concrete concepts and relationships that facilitate operationalization and application in practice. Middle range theories provide “a basic, usable structure of ideas . . .” (Smith & Liehr, 2008, p. 19). The CCM can be readily operationalized through the use of the CCA (Schim et al., 2003), developed to measure the four constructs of provider level cultural competence articulated in the model (cultural diversity experience, cultural awareness, cultural sensitivity, and cultural competence behaviors). Cultural competence can be operationally defined as the total score on the CCA, and hypothesized relationships

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between the four constructs and between cultural competence and other variables can be tested in a variety of circumstances. The CCA’s direct linkage to the CCM enhances its value as a research tool that facilitates theory evaluation. Fawcett’s (2005) third evaluative criterion addresses how well the theory has performed at describing, predicting, and/or explaining the phenomena to which it is related. The CCM has been used to examine variables associated with cultural competence among hospital-based health care providers (Schim, Doorenbos, & Borse, 2005), hospice nurses (Schim et al., 2006a), and the relationship between c­ultural competence and psychological empowerment among acute care nurses (Bauce, Kridli, & Fitzpatrick, 2014). The CCM has also been used to evaluate the effectiveness of cultural competence education training on cultural competence in hospice staff (Schim et al., 2006b). At its current stage of development, the CCM provides an incomplete conceptualization of the phenomenon of cultural competence because its four constructs refer only to individual health care provider characteristics. There is currently no published articulation of cultural competence constructs related to the client level that contributes to understanding cultural competence from the perspective of the recipient of care. In addition, while operational definitions of provider level cultural competence have been formulated, the CCM has seen limited use in predictive studies. In order for nursing research to generate empirically derived standards of culturally competent nursing practice, Smith (1998) argues for predictive studies with instruments “that measure cultural competence as received by clients and perceived by caregiver” (p. 8). A fourth evaluative criterion concerns whether or not the theory relates to and addresses the research hypotheses in its description and explanation. The CCM relates to and addresses the research hypotheses in this study in its description and explanation of the relationship between cultural competence and psychological empowerment among acute care nurses. The relatively concrete definitions of the constructs and relationships in the CCM have facilitated the ability to operationalize cultural competence for research and formulate testable hypotheses to examine ­cultural competence in a variety of nursing practice settings. The fifth criterion addresses whether the theory flows from the research question. Research questions are developed to test explanations of relationships between concepts in a theory (Fawcett, 2005). The research question in this study was developed to test a theoretical linkage between the four constructs of cultural competence, as defined in the CCM, and perception of psychological empowerment as a variable that may influence cultural competence in acute care nurses. The CCM guided the development of the research question, and the hypothesis tested was deduced from the theory. The sixth criterion is related to whether the theory addresses the primary and secondary research questions. The CCM addresses the primary research question in the current study of describing the relationship between cultural competence and psychological empowerment among acute care nurses. Because the CCM explains how the various aspects of provider level cultural competence are related to each other, the theory lends itself to the development of multiple research questions directed toward understanding the correlates of cultural competence. There has been no previous research exploring a potential relationship between the variables of cultural competence and psychological empowerment. The seventh criterion addresses whether the theoretical assumptions are congruent with the assumptions made for research. The assumptions in the CCM are



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partially congruent with the assumptions made for this research study in that there is a relationship between provider level cultural competence and previous diversity experience; specific cultural competence behaviors can be identified in practice; and providers of care must evaluate the desired outcome of culturally congruent care. Additional assumptions made for this research study based on a proposed theoretical linkage between cultural competence and perception of psychological empowerment are as follows: (a) cultural competence is related to nursing competence; (b) perceptions of psychological empowerment influence nursing practice; and (c) culturally congruent care requires cultural competence and psychological empowerment. The eighth criterion considers whether the theory is oriented to outcomes that are critical to patients. The CCM partially meets this criterion because it is oriented to attributes of health care providers that are required for culturally congruent care, which Schim and colleagues (2007) proposed as a requirement for quality health care. However, the CCM does not provide a domain that includes client outcomes, such as increased satisfaction with the care experience or improved self-care management. Smith (1998) characterizes theories of cultural competence as “irrelevant if principles do not translate directly into identifiable client outcomes” (p. 9). A final evaluative criterion concerns the availability of tools to test relationships of the theory. Burchum (2002) notes that the primary empirical referents for measuring cultural competence are self-assessment tools. In my study, the CCA was used to evaluate nurses’ level of cultural competence, and the Psychological Empowerment Questionnaire (PEQ; Spreitzer, 1995) was used to test the relationship between cultural competence and psychological empowerment. Currently there are no quantitative instruments that test the relationship between attributes of health care provider as articulated in the CCM and recipient of care evaluations and health outcomes.

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING Nursing conceptual models “provide the foundation for development of both clinical and scientific knowledge” (Fitzpatrick, 2005, p. 3) by guiding research, practice, and education. Nursing models with higher levels of abstraction become more difficult to use and measure (Whall, 2005) and apply to clinical practice. Schim (2005) acknowledges the difficulties of conceptualizing and measuring the complex construct of cultural competence in health care providers. Schim (2005) describes culturally congruent care as something that may be more readily understood when seen and experienced as a result of an appropriate interconnection of the various puzzle pieces described in the CCM. Schim and colleagues (2007) have used the CCM as the theoretical framework for research for the past 10 years. The model has been used to examine variables associated with cultural competence among urban hospital-based health care providers in the United States and Canada and among hospice nurses in the United States. Research results have led to a greater understanding of the significant relationship between prior diversity training and higher educational level of health care providers with cultural competence scores (Schim et al., 2005; Schim et al., 2006a). Study results also suggest that diversity training and education may enhance cultural competence by health care providers. Schim and colleagues (2006b) have also used the CCM as a framework for examining the effects of an education intervention on cultural competency in

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multidisciplinary hospice providers. The CCA instrument was used to measure participants’ cultural competence prior to and twice after a face-to-face education intervention program designed to increase knowledge of cultural diversity, cultural awareness, cultural sensitivity, and cultural competence. Study results indicated that cultural competence scores were significantly higher after the cultural competence education sessions than at baseline across all levels of hospice staff. The CCM and its assessment instrument have been used on a limited basis by other nurse researchers. Other cultural competence measurement instruments are more commonly used (Doorenbos et al., 2005) and are typically discipline-specific. However, the CCM continues to have utility for examining variables that contribute to cultural competence in health care providers across a variety of work settings. The theoretical framework and assessment instrument are easy to use, which facilitates the development of research hypotheses, new knowledge, and application to clinical practice.

USE OF THE THEORY IN THIS RESEARCH The CCM was used as the theoretical framework for describing the relationship between cultural competence and psychological empowerment among acute care nurses in a 425-bed urban hospital in southern Connecticut (Bauce et al., 2014). A quantitative descriptive correlational design was used with a convenience sample of acute care nurses working at the study facility. The participants (N = 120) completed survey questionnaires that included the CCA and the PEQ (Spreitzer, 1995), a 12-item instrument that measures the four subconstructs of psychological empowerment in the workplace (meaning, competence, self-determination, and impact). Study findings did not support a statistically significant relationship between total cultural competence and total psychological empowerment. However, the PEQ meaning subscale was significantly correlated with self-reported cultural competence, cultural competence behaviors, and total cultural competence; and the PEQ competence subscale was significantly associated with cultural competence behaviors. Study results also indicated that participants with more years of nursing experience had higher competence scores and higher self-reported cultural competence. Bauce and colleagues (2014) concluded that, “The meaning and competence dimensions of psychological empowerment may be more important to the manifestation of cultural competence than the other dimensions of psychological empowerment (self-determination and impact)” (p. 35). They also suggested that, “Nurses with more years of experience perceive themselves as having greater mastery of the skills required to provide care to patients from a broad range of cultural backgrounds and therefore assess themselves as having higher levels of cultural competence” (in press). In addition, the favorable self-assessment of cultural competence by the nurses in this study may have been related to their high rate of participation in prior diversity training and their moderate-to-high level of exposure to diversity. Using the Fawcett (2005) criteria, the CCM was further analyzed in relation to the research (see Table 10.1). Overall, it was judged that the model was very useful



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in the specific research and would be useful in descriptive studies. As currently developed, the CCM has less applicability in predictive studies. This is partially due to the fact that it is in the early stages of development and middle range theories must yet be derived based on both conceptual delineation and empirical research

Table 10.1 Evaluative Criteria and Use of Cultural Competence Model in the Study Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

The model describes the four constructs of provider level cultural competence and therefore fits the current study, which describes the relationship between cultural competence and psychological empowerment among acute care nurses.

2.

Is it readily operationalized?

Yes, the model uses the CCA (Schim, Doorenbos, Miller, & ­Benkert, 2003) developed to measure the constructs of provider level cultural competence, as articulated in the CCM (Schim, Doorenbos, B ­ enkert, & Miller, 2007).

3.

How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it relates?

The model has been used as a theoretical framework for examining variables associated with cultural competence among hospital-based health care providers (Schim, Doorenbos, & Borse, 2005), hospice nurses (Schim, Doorenbos, & Borse, 2006a), and the current study for describing the relationship between cultural competence and psychological empowerment among acute care nurses (Bauce, Kridli, & Fitzpatrick, 2014). The CCM has limited use in predictive studies.

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

The model relates to and addresses the research hypotheses in its description and explanation of the relationship between cultural competence and psychological empowerment among acute care nurses.

5.

Does the theory flow from the research question?

The question may potentially expand empirical knowledge regarding variables that influence cultural competence among acute care nurses. Therefore, the model provided the theoretical framework for developing the research question.

6.

Does the theory address the primary and secondary research questions?

The model addresses the primary research question of describing the relationship between cultural competence and psychological empowerment among acute care nurses.

7.

Are the assumptions congruent with the assumptions that are made for research?

The assumptions are partially congruent with the assumptions made for this research in that there is a relationship between provider-level and previous diversity experience; specific cultural competence behaviors can be identified in practice; and providers of care must evaluate the desired outcome of culturally congruent care. Additional research assumptions were made based on a proposed theoretical linkage between cultural competence and perception of psychological empowerment. (continued)

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Table 10.1 Evaluative Criteria and Use of Cultural Competence Model in the Study (continued ) Questions for evaluation

Responses to questions

8.

Is the theory oriented to outcomes that are critical to patients?

The model is partially oriented to outcomes that are critical to patients. It allows for the examination of variables that may influence culturally competent practice by health care providers. The CCM does not provide a domain that includes client and health outcomes.

9.

Are tools available to test relationships of the theory or do they need to be developed?

The CCA was developed to measure the constructs of provider level cultural competence as articulated in the model. The CCA was used in the current study to measure cultural competence in acute care nurses and describe its relationship with perceptions of psychological empowerment.

Adapted from Fawcett (2005).

testing the model. The CCA, developed by the authors of the CCM, is ­particularly useful for research purposes and has the potential to assist in the development of future research.

RECOMMENDATIONS FOR FURTHER RESEARCH Research using the CCM has primarily focused on examining variables associated with cultural competence in health care providers and assessing the effects of cultural competence education and training on cultural competence in providers. A significant limitation in using the theory in nursing research is the sole focus on provider attributes of cultural competence and the absence of a linkage to the client’s experience with and evaluation of care or to identifiable client outcomes. In addition, with complex constructs such as cultural competence, it is difficult to know if a theory clearly and completely defines the specific phenomenon of interest or is describing something related. In a concept analysis of cultural competence, Smith (1998) identified the following terms as being closely related to cultural competence: transcultural nursing, cultural brokerage, culturally informed, cultural sensitivity, cultural care, culturally appropriate, culturally diverse, cultural literacy, and cultural awareness. Future research in cultural competence may benefit from a methodology that merges similar concepts in what is described as convergence methodology (Fawcett, 2008). CCM-guided research must also include qualitative studies that explore nurses’ experiences with providing care to culturally diverse clients and nurses’ perceptions of culturally competent care. Garcia (2012) advocates developing micro theories related to culture as a means of addressing care needs for cultural subgroups within larger cultural groups. Garcia (2012) states, “Thus, emphasis on nurses’ experiences, events, and phenomena encountered while working with a cultural group should also be considered to formulate definitions, variables associations, and to develop a new theory and knowledge” (pp. 228–229). Additional research is required in the development of measurement tools that incorporate direct observation of provider behaviors rather than reliance on the



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provider’s self-reporting of cultural competence. Further, the ability to correlate provider behavior with client outcomes may provide a more complete understanding of culturally congruent care in practice.

SUMMARY Cultural competence has been a phenomenon of interest to the discipline of nursing since Madeleine (Leininger & McFarland, 2002) first linked care to culture. Culture theorizing has resulted in the development of several extant models of cultural competence ­(Campinha-Bacote, 1999; Giger & Davidhizar, 2002; Purnell, 2005), but it is still difficult to know, in a universal way, what effective culturally competent behavior looks like and its relationship to patient outcomes. It has even been suggested (Capell, Veenstra, & Dean, 2007) that theories of cultural competence developed in Western cultures may not be applicable in all cultural contexts. Although in its current stage of development the CCM focuses solely on provider level attributes of cultural competence, the theory has added to our knowledge of variables associated with cultural competence in nurses and has guided the development of intervention programs to increase cultural competence in nurses. The CCM has been successfully used as an organizing framework for research in a variety of practice environments and can inform the development of nursing practice to enhance outcomes for all patients regardless of social or cultural background. If cultural competence is fundamentally nursing competence, as Dreher and MacNaughton (2002) suggest, it is essential to understand the factors that facilitate professional practice. The CCM can play an important role in this endeavor.

References Bauce, K., Kridli, S. A., & Fitzpatrick, J. J. (2014). Cultural competence and psychological empowerment among acute care nurses. Online Journal of Cultural Competence in Nursing and Healthcare, 4(2), 27–38. doi:10.9730/ojccnh.org/v4n2a3 Burchum, J. (2002). Cultural competence: An evolutionary perspective. Nursing Forum, 37(4), 5–15. doi:10.1111/j.1744-6198.2002.tb01287.x Campinha-Bacote, J. (1999). A model and instrument for addressing cultural competence in health care. Journal of Nursing Education, 38(5), 203–206. Retrieved from http://www .cinahl.com/cgi-bin/refsvc?jid=227&aacno=1999048994 Capell, J., Veenstra, G., & Dean, E. (2007). Cultural competence in healthcare: Critical analysis of the construct, its assessment and implications. The Journal of Theory Construction & ­Testing, 11(1), 30–37. Doorenbos, A. Z., Schim, S. M., Benkert, R., & Borse, N. N. (2005). Psychometric evaluation of the cultural competence assessment instrument among healthcare providers. Nursing Research, 54(5), 324–331. Dreher, M., & MacNaughton, N. (2002). Cultural competence in nursing: Foundation or f­ allacy? Nursing Outlook, 50(5), 181–186. doi:10.1067/mno.2002.125800 Fawcett, J. (1985). Theory: Basis for the study and practice of nursing education. Journal of Nursing Education, 24(6), 226–229. Fawcett, J. (2005). Contemporary nursing knowledge. Analysis and evaluation of nursing models and theories (2nd ed.). Philadelphia, PA: F. A. Davis Company.

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Part II  Theories Applied to Research Fawcett, J. (2008). Advancing development of nursing theory: An innovative approach. Journal of Advanced Nursing, 63(5), 429. doi: 10.1111/j.1365-2648.2008.04766.x Fawcett, J. (2009). The relationship between theory and research: A double helix. In P. G. Reed & N. B. Crawford Shearer (Eds.), Perspectives on nursing theory (5th ed., pp. 28–37). Philadelphia, PA: Lippincott Williams & Wilkins. Fitzpatrick, J. (2005). Nursing knowledge development: Relationship to science and professional practice. In J. J. Fitzpatrick & A. L. Whall (Eds.), Conceptual models of nursing (4th ed., pp. 1–4). Upper Saddle River, NJ: Pearson Prentice Hall. Garcia, D. (2012). Letter to the editor. Nursing Philosophy, 13(3), 228–229. doi:10.1111/ j.1466-769X.201 Giger, J. N., & Davidhizar, R. (2002). The Giger and Davidhizar Transcultural Assessment Model. Journal of Transcultural Nursing, 13(3), 185–188. doi:10.1177/10459602013003004 Hardy, M. (2009). Theories: Components, development, evaluation. In P. G. Reed & N. B. Crawford Shearer (Eds.), Perspectives on nursing theory (5th ed., pp. 499–509). Philadelphia, PA: Lippincott Williams & Wilkins. Higgins, P. A., & Moore, S. M. (2009). Levels of theoretical thinking in nursing. In P. G. Reed & N. B. Crawford Shearer (Eds.), Perspectives on nursing theory (5th ed., pp. 49–56). Philadelphia, PA: Lippincott Williams & Wilkins. Krentzman, A. R., & Townsend, A. L. (2008). Review of multidisciplinary measures of cultural competence for use in social work education. Journal of Social Work Education, 44(2), 7–31. Kulwicki, A. D., Miller, J., & Schim, S. M. (2000). Collaborative partnership for culture care: Enhancing health services for the Arab community. Journal of Transcultural Nursing, 11(1), 31–39. doi:10.1177/104365960001100106 Leininger, M., & McFarland, M. R. (2002). Transcultural nursing: Concepts, theories, research, & practice (3rd ed.). New York, NY: McGraw Hill. Marra, J., Covassin, T., Shingles, R. R., Canady, R. B., & Mackowiak, T. (2010). Assessment of certified athletic trainers’ levels of cultural competence in the delivery of health care. Journal of Athletic Training, 45(4), 380–385. Purnell, L. (2005). The Purnell model for cultural competence. Journal of Multicultural Nursing & Health, 11(2), 7–15. Schim, S. M. (2005). A picture on the front of the box. Journal of Professional Nursing, 21(5), 255–256. doi:10.1016/j.profnurs.2005.08.001 Schim, S. M., Doorenbos, A., Benkert, R., & Miller, J. (2007). Journal of Transcultural Nursing, 18(2), 103–110. doi:10.1177/1043659606298613 Schim, S. M., Doorenbos, A. Z., & Borse, N. N. (2005). Cultural competence among Ontario and Michigan healthcare providers. Journal of Nursing Scholarship, 37(4), 354–360. Schim, S. M., Doorenbos, A. Z., & Borse, N. N. (2006a). Cultural competence among hospice nurses. Journal of Hospice and Palliative Nursing, 8(5), 302–307. Schim, S. M., Doorenbos, A. Z., & Borse, N. N. (2006b). Enhancing cultural competence among hospice staff. American Journal of Hospice and Palliative Medicine, 23(5), 404–411. doi:10.1177/1049909106292246 Schim, S. M., Doorenbos, A. Z., Miller, J., & Benkert, R. (2003). Development of a cultural competence assessment instrument. Journal of Nursing Measurement, 11(1), 29–40. Schim, S. M., & Miller, J. E. (1999). Cultural competence core components. Detroit, MI: Henry Ford Health System/Oakland University Center for Academic Nursing. Retrieved from [email protected] Smith, L. S. (1998). Concept analysis: Cultural competence. Journal of Cultural Diversity, 5(1), 4–10.



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Smith, M. J., & Liehr, P. R. (2008). Understanding middle range theory by moving up and down the ladder of abstraction. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing (2nd ed., pp. 13–31). New York, NY: Springer Publishing Company. Spreitzer, G. M. (1995). Psychological empowerment in the workplace: Dimensions, measurement, and validation. Academy of Management Journal, 38(5), 1442–1465. Walker, L., & Avant, K. (2005). Strategies for theory construction in nursing (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Whall, A. L. (2005). The structure of nursing knowledge: Analysis and evaluation of practice, middle range, and grand theory. In J. J. Fitzpatrick & A. L. Whall (Eds.), Conceptual models of nursing (4th ed., pp. 5–20). Upper Saddle River, NJ: Pearson Prentice Hall.

chapter 11

Interpersonal Relations in Nursing Theory Jeffrey S. Jones

Interpersonal Relations in Nursing is a theoretical conceptual model of the practice of nursing as proposed by Hildegard E. Peplau. The theory, derived from Harry Stack Sullivan’s Interpersonal Relations in Psychiatry Model (1953), was reconceptualized for the practice of nursing by Peplau and was first developed and published in Interpersonal Relations in Nursing in 1952. Although published a year prior to Sullivan officially publishing his work, her theory is based on the concepts he was developing during their time together. Peplau has been referred to as the “mother” of psychiatric nursing and, in an authorized biography by Callaway (2002), as the psychiatric nurse of the century. She was well known among the global nursing community not only for her contributions to psychiatric nursing but also for her activism throughout nursing, both at the national level through the American Nurses Association (ANA) and at the global level through the International Council of Nurses (ICN). During her professional career, she served as president of the ANA and subsequently as the ANA executive director. She also served as a board member of the ICN and, in 1997, received the highest award from this organization, the Christine Reimann Prize. Peplau was always a staunch supporter of professional education of nurses and specialization post–basic preparation. She was actually responsible for developing the very first master’s degree program in nursing at Rutgers University School of Nursing in New Jersey (Jones & Fitzpatrick, 2012).

BASIC DESCRIPTION OF THE THEORY Peplau proposed that at its core, the practice of nursing is essentially an interpersonal process between two or more persons in which activities are directed toward a therapeutic goal. She explicates that the attainment of the therapeutic goal, usually health, is achieved by the nurse’s deliberative actions along a sequence of stages. Peplau believed that the interpersonal competencies of nurses are key to assisting patients to regain health and well-being. Initially she described four phases in the interpersonal process (orientation, identification, exploitation, and resolution) (Peplau, 1952). These four stages were later condensed into three (orientation phase, working phase, and resolution phase) (Peplau, 1997). The original four-stage model is discussed in this chapter.

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Hildegard Peplau published the first contemporary book proposing a theoretical paradigm for nursing practice. This was the result and outgrowth of her graduate work with Harry Stack Sullivan and his Interpersonal Theory of Psychiatry at the famous Chestnut Lodge in Washington, DC. She termed the model a “conceptual frame of reference” (Peplau, 1991). Sullivan, an American psychiatrist, rose to prominence in the 1920s and 1930s by asserting that personality is shaped almost entirely by the relationships we have with other people, that the maternal figure (or mother) figures significantly into shaping relationship patterns. Sullivan is most remembered for the conceptualization of seven developmental stages in the evolution of personality (Evans, 1996). In kind, Peplau asserted that when a nurse (maternal figure) and patient are interacting, the interpersonal dynamics of her model define the relationship and ultimately determine the patient’s experience. The aforementioned four phases of the nurse–patient relationship must be recognized and navigated for optimal care to be delivered and desired outcomes to be achieved.

CORE CONCEPTS The interpersonal process starts at the first meeting between the nurse and the patient, which is when the orientation phase begins. In this phase, the nurse and patient are first introduced and become acquainted with each other. This typically occurs during the first nursing assessment. The nurse’s goal is to try to understand the patient’s problem as fully as possible and at the same time present himself or herself as caring, knowledgeable, and trustworthy. If this is successfully done, the patient will accept the nurse as someone who can help. The nurse–patient relationship then moves into the second phase of development, termed identification. In Peplau’s description of identification, the patient has found qualities or traits in the nurse that have now allowed the patient to trust and be cared for by him or her. The patient now perceives the nurse as knowledgeable, trustworthy, and caring, and understands that there is an element of dependency in his or her role as patient. The nurse is aware of the trust in the relationship and begins to look for opportunities to begin fostering independence to reinforce a sense of mastery and competency. The reinforcement of interdependence and independence in the relationship occurs though a dynamic process between the patient and the nurse. As the patient begins taking advantage of these opportunities presented by the nurse, there is movement from dependence toward interdependence. This signals readiness to move into the exploitation or working phase of the relationship. The nurse, skillfully gauging the progression of the relationship, guides the process. During the exploitation phase, the patient feels comfortable enough to take full advantage of the services being offered and begins to assume more independence as he or she experiences the relationship with the nurse (Peterson & Bredow, 2004). The last phase of the nurse–patient relationship, resolution, is characterized by termination of the relationship due to a sense of independence and goals being met. The patient becomes independent in mastery of self-care skills and may experience a sense of security and release that occurs because help was received in the time of need. The patient now exits the relationship with the nurse as he or she is no longer dependent. The nurse is also expected to free himself or herself from the relationship with the patient (Jones & Fitzpatrick, 2012).



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Additionally, Peplau (1952) described six roles that nurses may find themselves cast in during the four phases of the process. The roles may overlap and can occur during any phase of the relationship.

Stranger This role usually occurs during the orientation phase. Because the nurse and patient are strangers to each other, it is important for the nurse to create a climate of courtesy and acceptance. The nurse should not prejudge the patient. By treating the patient in this manner, the identification phase is then facilitated.

Resource Person In this role, the patient discovers that the nurse is a valuable source of information. It is the nurse’s responsibility to determine how best to answer these and other questions: Are there larger issues that need to be addressed? How much information can the patient handle at this point in the illness? Is the patient ready to hear the response you are about to give?

Teacher Nurses engage in teaching activities with patients at many points throughout the illness experience. When an opportunity to function in this role presents itself to the nurse, he or she needs to decide what mode best suits the situation. Should this be a brief instructional moment with review of printed material? Should this be an experiential meeting with the nurse demonstrating something and having the patient then perform the task? The nurse’s understanding of where he or she is in the relationship will best guide the choice. For example, a patient is more apt to take full advantage of any learning opportunities while in the exploitation phase as opposed to the orientation phase.

Leader During this role, the nurse guides or helps the patient toward meeting any health care task with cooperation and active participation.

Surrogate It is not uncommon for patients to see the people who care for them as they would others who have cared for them in their life (e.g., a parent, sibling, or spouse). Once it is discovered that this is happening, it is important for the nurse to assist the patient in developing an awareness of this mindset and then assist the patient in understanding the difference from the recalled person.

Counselor In this role the nurse emphasizes therapeutic communication strategies and has full awareness of therapeutic use of self in the encounters with the patient. The expected outcome is that the patient will be able to integrate the illness into his or her life rather than see it as a separate experience.

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Communication and interviewing skills are essential for the nurse to help the patient through the phases of the interpersonal relationship. Further, Peplau (1997) delineates the key observation skills needed by the nurse. She describes the need for participant observation, which consists of the following three foci: the nurse, the patient, and the relationship. Thus, the nurse must be ever vigilant about self and other, as well as the interaction between self and patient. The nurse must be aware of all of the messages, verbal and nonverbal, communicated to patients. As a component of the observation required in the nurse–patient interaction, Peplau describes empathic linkages—the ability to feel in oneself the emotions experienced by another person in the same situation. It is the nurse’s role to reframe the observed feelings into verbal communications. Peplau (1997) noted several challenges in the interpersonal relationships that developed between nurses and patients: avoiding rather than dealing with the patient’s anger or one’s own anger, avoiding discussion of emotionally laden topics, and competing with the patient on some dimension. As these challenges test the nurse’s competence, it is important for the nurse to identify them and their effect on the nurse–patient relationship. The awareness of boundaries in the relationship requires vigilance to maintain a therapeutic manner (Jones, Fitzpatrick, & Drake, 2008). Peplau (1997) understood that patients want relationships with others, including therapeutic relationships with nurses. The connectedness developed through the interpersonal relationship helps decrease the anxiety in many patients’ experiences. The relationship further serves as a means to decreasing the space between persons.

RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS THEORY Peplau’s (1952) nursing theory can most closely be linked to Sullivan’s Interpersonal Theory of Psychiatry. Although some work is occasionally done regarding the applicability of Sullivan’s theory to current interventions in clinical practice, it rates low in its ability to generate research (Evans, 1996). Review of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) reveals no active research on Peplau’s theory from disciplines other than nursing.

RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS Peplau (1991) offers definitions of nursing, person, health, and environment germane to the nursing metaparadigm as follows: Nursing: A significant, therapeutic, interpersonal process. It functions cooperatively with other humans’ processes that make health possible for individuals. Nursing is an educative instrument, a maturing force that aims to promote forward movement of personality in the direction of creative, constructive, productive, ­personal, and community living. Person: Man is an organism that lives in an unstable equilibrium. Health: A word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, ­personal, and community living.



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Environment: Existing forces outside the organism and in the context of culture from which mores, customs, and beliefs are acquired. However, general conditions that are likely to lead to health always include the interpersonal process. (Peplau, 1991).

THEORY ANALYSIS Peplau’s theory was evaluated using Fawcett’s (2005) criteria for theory evaluation (see Table 11.1). Overall, theories evaluated in this manner are scrutinized for their significance, internal consistency, parsimony, testability, empirical adequacy, and pragmatic adequacy. Peplau’s theory was evaluated along these domains by examining goodness of fit, operationalization, relativity, applicability to hypothesis, flow, ability to address primary and secondary questions, presence of theoretical assumptions, the relationship to patient outcomes, and overall theory testability. As shown in the table, the areas of concern were adequately addressed in fulfilling the criteria. TABLE 11.1 Evaluative Criteria and Use of Theory of Interpersonal Relations Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

The theory focuses on the relationship dynamic between the nurse and the patient and thus serves as a model for relationship-based/driven care where boundaries need to be navigated.

2.

Is it readily operationalized?

Yes, the original model is divided into four distinct yet overlapping phases (orientation, identification, exploitation, resolution).

3.

How well has the theory performed at describing, ­predicting, and/or explaining the phenomena to which it relates?

The Theory of Interpersonal Relations in Nursing is well studied and continues to be present in the literature with regard to practice, care, and boundaries. Some recent examples are Peden (1993), Kai and Crosland (2002), and Pohlman (2006).

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

The theory relates to and addresses the research hypotheses in its explanation of the relationship between nurses more likely to practice from an interpersonal model (BSN) versus nurses less likely to practice from an interpersonal model (ADN), as well as the correlation to frequency of boundary violations in the nurse–patient relationship.

5.

Does the theory flow from the research question?

The question has the potential to expand knowledge relating to the study of interpersonal curricula (or lack of) at the undergraduate level and its impact on the style of professional practice and correlation to boundary violations in the nurse–patient relationship. Therefore, the theory guided the development of the research question and hypotheses. (continued)

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TABLE 11.1 Evaluative Criteria and Use of Theory of Interpersonal Relations (continued) Questions for evaluation

Responses to questions

6.

Does the theory address the primary and secondary research questions?

The theory addresses the primary and secondary research questions, that is, to describe a correlation between the frequency of the boundary violations between ADN- and BSN-prepared nurses and to suggest a correlation to curricular influences based on interpersonal (or lack of) content in these programs respectively, serving as a model for practice.

7.

Are the assumptions congruent with the assumptions that are made for research?

The assumptions are congruent with the assumptions that are made for the research in that (explicit) (a) the kind of person the nurse becomes makes a substantial difference in what each patient will learn as he or she receives nursing care, and (b) fostering personality development toward maturity is a function of nursing and nursing education. Nursing uses principles and methods that guide the process toward resolution of interpersonal problems. Finally (implicit), (c) the ­nursing profession has legal responsibility for the effective use of nursing and its consequences to patients.

8.

Is the theory oriented to outcomes that are critical to patients?

The theory is oriented to outcomes that are critical to patients. It provides a conceptual framework for the nurse delivering care so that, when utilized as described, the nurse moves the patients’ experience forward interpersonally in terms of ­personal growth and awareness.

9.

Are tools available to test relationships of the theory or do they need to be developed?

McNaughton (2005) performed a case study with five nurse–patient groups to determine if Peplau’s (1952) theory of the nurse–patient relationship was correct. The table showed all relationships began in the orientation phase. Then the groups entered the working phase on or after the second visit; multiple visits were needed for patients to develop trust and discuss problems. For example, group E entered the working phase on visit 2 with 59.8% interaction compared with 30.2% interaction in the working phase on the first visit. These findings support Peplau’s theory for the development of the nurse–patient relationship because as the relationship progressed through the phases, the interaction increased.

Adapted from Fawcett (2005) and Peplau (1997).

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING Interest in Peplau’s work and its applicability to the concept of nurse–patient relationships endure today. Forchuk (1998) studied the identification and exploitation phases of Peplau’s model and combined them in a term called the working phase. The concept of working in a therapeutic relationship is not new to models of interpersonal relationships. In Forchuk’s study, 10 nurse–patient relationships were examined through interviews with the nurse, patient, and investigator using the above defining characteristics of the identification and exploitation phases to determine achievement of the



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working phase. Influences that prevented movement into this phase were identified as the nurse’s unavailability, a sense of distance or inequality, differences in realities and values, and mutual withdrawal from the relationship. Empirical indicators that fostered movement into the working phase were identified as themes of trust, availability, and consistency, along with the perceived attitude of the nurse, the nature of the planned therapeutic sessions, and what happened between the sessions. Peplau (1991) identified 13 assumptions of her model. The most significant assumption related to the present project is that Interpersonal Relations in Nursing occur in all areas of nursing. It should not be assumed to only be germane to psychiatric/mental health nursing. Every nurse–patient encounter is an interpersonal opportunity (Peterson & Bredow, 2004). The nurse must be mindful of the evolving relationship and the responsibilities associated with it. Awareness of self is particularly important to Peplau’s model; as stated previously, it was felt that the kind of person the nurse becomes makes a substantial difference in what each patient will learn as that patient receives nursing care (Peplau, 1991).

USE OF THE THEORY IN THIS RESEARCH Neotheoretical Model Peplau’s (1952) Interpersonal Relations in Nursing Model is derived from Harry Stack ­Sullivan’s Interpersonal Theory of Psychiatry and was used in this research. Peplau’s theory describes four phases of the nurse–patient relationship as it unfolds and develops. They are overlapping, but each has unique elements that are separate from the rest. Her model also describes six roles that the nurse may be cast in during any of the four phases. There are nurse–patient encounters that, because of the nature of the situation at hand and the time frame involved, show the development of the relationship will clearly be on a linear trajectory. There will be other nurse– patient encounters where the relationship may be ongoing, and because of the time frame the relationship will continue to evolve and develop over and over again in a more cyclical ­fashion. Figure 11.1 illustrates this application of Peplau’s concepts in Figure 11.1  Peplau's Model of Interpersonal Relations with nursing roles (as conceptualized by J. Jones, 2013).

Surrogate

Orientation

Stranger

Resourse Person

Identification

Counselor

Exploitation

Leader

Resolution

Teacher

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a nurse–patient relationship that has four distinct phases yet is overlapping, potentially cyclical, and at each phase potentially influenced by the six roles nurses may assume in the therapeutic relationship. Peplau’s Interpersonal Theory of Nursing practice was used in assessing possible linkages to boundary violations in nursing (postlicensure) in programs that may have less interpersonal curricular content (Jones, 2007). Interpersonal Relations course content varies widely across BSN programs and between BSN and ADN programs. Trends regarding Interpersonal Relations in Nursing have ranged from this being a common theme woven through the entire curricula to all of the content presented in the mental health course and clinical experiences (National League of Nursing [NLN], 2003). Recent trends in programs of nursing, particularly in ADN programs, have been to include more skill utilization content, particularly technical skills, to implement the medical regimen. Educators in ADN programs are often faced with the need to increase technical skill content as the science of health care progresses. There were very few studies identified in which the focus was on interpersonal content in prelicensure education in nursing. The closest curricular content studies involved topics of stress management, modeling interpersonal skills between student and instructor, and a comparison of interpersonal behaviors between diploma and baccalaureate programs.

Prior Research Related to Educational Programs Manderino, Ganong, and Darnell (1988) surveyed 276 baccalaureate programs for content that focused on stress management in working with patients. Only 27, or 10%, of the sample confirmed that this topic was included as one separate course. The other respondents indicated that this topic was incorporated discretely throughout the entire curricula. With regard to basic communication skills, Shattell (2004) reported that having students participate in research group discussions with faculty strengthened interpersonal skills between the student and the instructor. Eight students met weekly for 4 hours off campus with two faculty members. The students engaged in research question discussions and wrote a two-page reflective paper each week. In a study in the United Kingdom, nominal group technique was used successfully by Perry and Linsley (2006) with prelicensure nursing students to aid in the teaching of assessment and summation skills during their mental health rotation. Over the course of 3 years (2001 to 2003), 36 nursing students took part in the nominal groups that were run annually. The choice of nominal group technique was made due to the advantages of this strategy fostering individual participation and communication while lessening the impact of power relations. Role-play proved to be the most identifiable element fostering assessment skills. Al-Ma’aitah, Rajacich, and Khasawneh (1995) found that among Jordanian nursing students (N = 536) in diploma and BSN programs, there was no difference in interpersonal behaviors overall based on self-report. A questionnaire based on six dimensions of interpersonal behavior was used. The researcher also discovered that male nursing students had more desire to control the interpersonal process than the female students. There has been minimal research focused on descriptions of curricular content within ADN programs. The Texas study by Poster and colleagues (2005) was focused on core competencies that included the relational aspect of nursing. These researchers compared 14 core competencies between licensed vocational nursing (LVN), diploma/ADN, and BSN programs. One of the competencies, that of provider of care,



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contained the content related to the nurse–patient relationship. The knowledge level for diploma/ADN programs was at the ability to formulate goals and outcomes in the plan of care based on nursing diagnosis in collaboration with patients and other health team members. Diploma/ADN programs were found to teach techniques of written and verbal communication rather than theoretical models in establishing the nurse–patient relationship. There was a lack of literature regarding curricular content on interpersonal relations in prelicensure educational programs in nursing. Further, there was a lack of documentation on how students in prelicensure programs are educated to implement the nurse–patient relationship. This study (Jones, 2007) analyzed disciplinary data in Ohio from 2002 to 2006 and found a difference in postlicensure frequency of incidents of boundary violations between ADN and BSN graduates. In Ohio between 2002 and 2006, ADN-prepared RNs had a statistically higher frequency of boundary violation than BSN-prepared RNs. A higher percentage of ADN-prepared RNs also had experienced previous disciplinary action. It was proposed that a possible correlation between levels of interpersonal content and frequency of boundary violations existed between ADN and BSN programs.

RECOMMENDATIONS FOR FURTHER RESEARCH Because of the lack of consistent data regarding the presence of interpersonal curricula in programs of nursing, an in-depth study should be undertaken that could encompass a larger population, including a longitudinal study of curricular data encompassing all prelicensure education routes (ADN, BSN, diploma, and certificate). A comparison between the four groups may yield more detailed results. Second, nurse educators are called upon to examine core content in prelicensure curricula for evidence and prevalence of interpersonal content. Programs of nursing education should ask to what extent educators are preparing students to deliver care through the interpersonal model nurse–patient relationships. Scrutiny around these issues and role-modeling the interpersonal process with students could prove immensely important in addressing the problem. Peplau (1991) published suggestions on designing nursing education from an interpersonal perspective, and these may prove useful. Faculty development reinforcing the importance of Interpersonal Relations in Nursing as a cornerstone of basic nursing education may need to take place. Future research could also focus on evaluating existing curricula in more detail and discovering opportunities for change to strengthen interpersonal curricula based on ­Peplau’s model (Jones, Fitzpatrick, & Drake, 2008).

SUMMARY Hildegard Peplau’s Theory of Interpersonal Relations in Nursing continues to prove relevant to the practice of nursing and still serves as a useful conceptual model of practice. It is viewed by some as a middle range theory; it is readily operationalized and can be used by generalist nurses and advanced practice nurses alike. With ­relationship-based care initiatives becoming prominent features of major health care systems, Peplau’s theory fits well in guiding practice within these paradigms. The conceptual model itself may also be portable for use in other human service disciplines.

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References Al-Ma’aitah, R., Rajacich, D., & Khasawneh, J. (1995). Jordanian nursing students’ interpersonal behaviors. Health Care Women International, 16(3), 213–220. Callaway, B. J. (2002). Hildegard Peplau: Psychiatric nurse of the century. New York, NY: Springer Publishing Company. Evans, F. B. (1996). Harry Stack Sullivan: Interpersonal theory and psychotherapy: Makers of modern psychotherapy. New York, NY: Routledge. Fawcett, J. (2005). Criteria for evaluation of theory. Nursing Science Quarterly, 18(2), 131–135. Forchuk, C. (1998). Factors influencing movement of chronic psychiatric patients from the orientation to the working phase of the nurse-patient relationship. Perspectives in Psychiatric Care, 34(1), 36–44. Jones, J. (2007). Frequency of post-licensure registered nurse boundary violations with patients in the State of Ohio: A comparison based on type of pre-licensure registered nurse education (Doctoral project). Case Western Reserve University, Cleveland, OH. Jones, J., Fitzpatrick, J. J., & Drake, V. (2008). Frequency of post-licensure registered nurse boundary violations with patients in the State of Ohio: A comparison based on type of pre-licensure registered nurse education. Archives of Psychiatric Nursing, 22(6), 356–363. Jones, J. S., & Fitzpatrick, J. J. (2012). Interpersonal Relations: The cornerstone of psychiatric nursing. Using interpersonal nursing theories and models to guide practice in the nurse– patient relationship. In J. S. Jones, J. J. Fitzpatrick, & V. L. Rogers (Eds.), Psychiatric mental health nursing: An interpersonal approach. New York, NY: Springer Publishing Company. Kai, J., & Crosland, A. (2002). People with enduring health problems describe the importance of communication, continuity of care, and stigma. Evidenced Based Nursing, 5(3), 93. Manderino, M. A., Ganong, L. H., & Darnell, K. F. (1988). Survey of stress management in baccalaureate nursing curricula. Journal of Nursing Education, 27(7), 321–325. National League of Nursing. (2003). Retrieved December 20, 2006, from www.nln.org Peden, A. R. (1993). Recovering in depressed women: Research with Peplau’s theory. Nursing Science Quarterly, 6(3), 140–146. Peplau, H. (1952). Interpersonal Relations in Nursing. New York, NY: Putnam. Peplau, H. (1991). Interpersonal Relations in Nursing. New York, NY: Putnam. Peplau, H. E. (1997). Peplau’s Theory of Interpersonal Relations. Nursing Science Quarterly, 10(4), 162–167. Perry, J., & Linsley, L. (2006). The use of nominal group techniques as an evaluative tool in the teaching and summative assessment in the teaching of interpersonal skills of student mental health nurses. Nursing Education Today, 26, 346–353. Peterson, S. J., & Bredow, T. S. (2004). Middle range theories: Application to nursing research. Philadelphia, PA: Lippincott, Williams and Wilkins. Pohlman, M. (2006). The nurse–patient relationship: Results of an examination about relationships between patients and nurses in hospitals. Pflege, 19(3), 156–162. Poster, E., Adams, P., Clay, C., Garcia, B. R., Hallman, A., Jackson, B., Klotz, L., . . . Yuill, N. (2005). The Texas model of differentiated entry-level competencies of graduates of nursing programs. Nursing Education Perspectives, 26(1), 18–23. Shattell, M. (2004). Using an interpretive research group to teach communication and understanding in undergraduate psychiatric-mental health nursing students. Journal of Nursing Education, 43(10), 479–480. Sullivan, H. S. (1968). The interpersonal theory of psychiatry. New York, NY: W. W. Norton & Company.

chapter 12

Theory of Work Engagement Margaret O’Connor M ­ urphy

The concept of work engagement first began to surface circa 1990, following the publication of Kahn’s (1990) study of psychological conditions of personal engagement and disengagement at work. Prior to Kahn’s study, the focus was on negative poles of psychology, including the concept of burnout. There is extant research on burnout across multiple professions whose roots are based in human service; for example, health care, education, and social services. However, as psychological research began to shift toward more positive aspects of well-being among workers, with a focus on human strengths and optimal functioning, work engagement viewed as the opposite of burnout emerged as a new field with a theoretical foundation (Schaufeli, Salanova, González-Romá, & Bakker, 2002).

BASIC DESCRIPTION OF THE THEORY Kahn’s Work Engagement Theory Kahn (1990) was the first scholar to define engagement as “the harnessing of organization members’ selves to their work roles; in engagement, people employ and express themselves physically, cognitively, emotionally and mentally during role performances” (p. 694). Kahn further defined personal disengagement as “the uncoupling of selves from work roles; in disengagement, people withdraw and defend themselves physically, cognitively, or emotionally during role performances” (p. 694). Personal engagement is evident when a person’s “preferred self” is manifested in role performance. To explain preferred self, Kahn states, “People have dimensions of themselves that, given appropriate conditions, they prefer to use and express in the course of role performance” (p. 700). Expressing one’s preferred self involves personal engagement and denotes presence where one is connected to one’s work and to others. Based on his research analyses, Kahn (1990) identified three psychological conditions exhibited in task behaviors. These conditions are meaningfulness, safety, and availability. Meaningfulness is defined as “a sense of return on investments of self in role performances”; safety is defined as “a sense of being able to show and employ

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self without fear of negative consequences”; and availability is defined as “a sense of possessing the physical, emotional, and psychological resources necessary for investing self in role performances” (p. 705). Psychological meaningfulness is influenced by task characteristics, role characteristics, and work interactions. Task characteristics result in meaningfulness when employees perceive that they are working autonomously on tasks that allow the use of existing abilities and demand the development of new skills. Such work provides opportunities for maintaining current competencies while fostering growth and development. Role characteristics provide meaningfulness when employees perceive their role as significant, valuable, and influential, rather than leading to a sense of powerlessness. Work interactions create psychological meaningfulness for employees through positive and rewarding exchanges with colleagues and customers. This type of communication promotes a sense of self-worth and dignity (Kahn, 1990). Psychological safety is predominantly influenced by trusting interpersonal relationships, group and intergroup dynamics, a supportive management style and process, and acceptance of organizational norms. It evolves when the organizational culture supports employees feeling safe to express themselves, to take risks, and to execute change without fear of consequences. A clear understanding of roles and expectations promotes psychological safety (Kahn, 1990). Psychological availability stems from having the psychological, physical, and emotional resources to effectively engage in one’s work despite distractions. Significant distractions lead to depletion of physical and emotional energy and individual insecurity and affect a person’s outside life. The depletion of physical energy levels renders an inability to meet the demands of personal engagement and leads to psychological unavailability. Being emotionally available to invest oneself in work facilitates personal engagement, while insecurity, lack of self-confidence, and selfconsciousness create distractions and decrease personal engagement. In addition, distractions resulting from being preoccupied with life events may result in personal disengagement at work (Kahn, 1990).

Schaufeli’s Work Engagement Theory Schaufeli, Salanova, González-Romá, and Bakker, leaders in the field of work engagement, defined work engagement as a “positive, fulfilling, work-related state of mind that is characterized by vigor, dedication and absorption” (Schaufeli et al., 2002, p. 74). They identified three components of the concept of engagement. Vigor is characterized by high levels of energy and mental resilience while working, the willingness to invest effort in one’s work, and persistence even in the face of difficulties. Dedication is characterized by a sense of significance, enthusiasm, inspiration, pride, and challenge. Absorption is characterized by being fully concentrated and deeply engrossed in one’s work, whereby time passes quickly and one has difficulties with detaching oneself from work. Schaufeli and colleagues (2002) agree that work engagement is the antithesis of burnout, which is characterized by exhaustion and cynicism, stating that vigor and dedication are the direct opposites of exhaustion and cynicism. In contrast to Kahn’s theory of engagement, where engagement is a work role, the theory of work engagement as the antithesis of burnout equates engagement to a work activity or the work itself, rather than the role (Bakker, Schaufeli, Leiter, & Taris, 2008).



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Maslach and Leiter’s Work Engagement Theory Schaufeli et al. (2002) examined Maslach’s and Leiter’s (1997) definition of engagement, in which engagement is characterized by three elements: energy, involvement, and efficacy. These are the exact opposite of the burnout characteristics of exhaustion, cynicism, and lack of professional efficacy. Maslach and Leiter’s (1997) three elements are similar to the elements identified by Schaufeli and colleagues (2002). Energy equates to vigor and involvement equates to dedication. However, efficacy differs from absorption and is more focused on the ability to deal effectively with job demands. Schaufeli and colleagues agree that while engagement is conceptually the opposite of burnout, it has structural and measurement differences and, “as a consequence, engagement is operationalized in its own right” (p. 75). As such, Schaufeli, Bakker, and Salanova (2006) developed an instrument to empirically measure work engagement as a separate entity from burnout. This self-report instrument, the Utrecht Work Engagement Scale (UWES), has been tested and used internationally to measure levels of work engagement; it is psychometrically valid and reliable. Research on positive organizational behaviors is explained as “the study and application of positively oriented human resource strengths and psychological capacities that can be measured, developed and effectively managed for performance improvement in today’s workplace” (Luthans, 2002, p. 59). Building on the work of Bakker et al., (2008), in which gaps were identified in research on positive organizational behaviors, Bakker and Demerouti (2008) focused on the newly introduced concept of work engagement. Qualitative and quantitative studies were examined in an effort to understand how engagement is manifested and to identify its antecedents and consequences. Studies examined by Bakker and Demerouti revealed that engaged employees have a positive attitude, are more self-efficacious, and have high energy. Engaged employees are viewed as inspirational and happy. Understanding the relationship between the theoretical framework for work ­engagement and job resources and job demands requires a closer look at the Job Demands-Resource (JD-R) Model. According to Demerouti, Bakker, Nachreiner, and Schaufeli (2001), resources are health-protecting factors. The factors that comprise job resources include physical, psychological, social, or organizational aspects of work, which are linked to an ability to “be functional in achieving work goals; reduce job demands at the associated physiological and psychological costs; stimulate ­personal growth and development” (p. 501). Thus, these resources are necessary for job performance. Job demands are also comprised of physical, social, or organizational aspects of work. When job demands exceed an employee’s limits or the necessary job resources are lacking to perform the tasks, there are physiological and psychological costs; for example, exhaustion. There is support to show that job resources play a pivotal role in decreasing and mitigating job demands (Bakker, Demerouti, Hakanen, & Xanthoupoulou, 2007). Job resources are considered buffers for job demands that may lead to burnout. According to Bakker et al. (2008), “Job resources either play an intrinsic motivational role because they foster employees’ growth, learning and development, or they play an extrinsic motivational role because they are instrumental in achieving work goals” (p. 191). The JD-R Model reflects how job demands lead to mental, emotional, and physical burnout, depleting health and energy and ultimately leading to negative organizational outcomes. Looking at the positive pole, job engagement, it is clear to see that job resources can enhance personal resources, which then lead to motivation and positive organizational outcomes (Bakker & Demerouti, 2007).

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Salanova, Schaufeli, Xanthopoulou, and Bakker (2010) define gain spirals as “amplifying loops in which cyclic relationships among constructs build on each other positively over time” (p. 119). In looking at gain spirals for resources and engagement, they explain that for gain spirals to exist, two conditions must be met: a reciprocal relationship must be established by two-way causation and there must be an increase over time. They also note that causation requires the use of true experimental design and random assignment. However, given the challenges of such studies on engagement, confidence in causal relationships can be built by the use of theory-grounded, longitudinal studies. Three psychological theories were introduced to better understand gain spirals of resources and work engagement. These theories are the Conservation of Resources Theory, the Social Cognitive Theory, and the Broaden-and-Build Theory. Selected for their motivational nature, these three theories, though general, offer specificities that can be related to resources and engagement and therefore become integral in developing and explaining reciprocity and upward spiraling relationships.

Conservation of Resources Theory The Conservation of Resources Theory provides a framework for understanding stress and successful adaptation. Those who acquire and maintain the four main resources (objects, conditions, personal characteristics, and energies) will have the ability to handle stressors. As a result of these resources, vulnerability will be lessened; likewise, protecting and accumulating resources predicts decreased stress. The theory also postulates that the more resources a person possesses, the more likely the person will continue to accumulate and gain additional resources, creating “resource caravans” (the linking and accumulating of resources). Ultimately, the acquisition of resources results in gain spirals. This can also happen in the reverse and is termed loss spirals, where resources are depleted and burnout ensues. To determine if gain spirals are applicable to work engagement, Salanova et al. (2010) examined six longitudinal studies regarding resources and work engagement. Results of these studies reveal reciprocal relationships between the following concepts: (a) work engagement and job resources; (b) work engagement and personal initiative; (c) personal resources (self-efficacy)/job resources (social support climate and clear goals) and work-related flow (akin to engagement); (d) personal resources (efficacy beliefs) and task resources (time control and method control); and (e) job/ personal resources and work engagement. Furthermore, certain resources have the capacity to boost engagement; for example, coaching and feedback improve employee optimism, making it more likely that employees will become more engaged. The reciprocal relationships of these concepts, resource caravans, and gain spirals are aligned with the Conservation of Resources Theory.

Social Cognitive Theory Social Cognitive Theory is rooted in the belief that humans, through their capabilities, have the capacity to control their lives. An individual’s sense of self-efficacy provides the power and motivation to ensure that one’s actions realize desired outcomes. Likewise, collective self-efficacy is the collective power to achieve desired outcomes. Much of the literature on self-efficacy has centered on job performance. However, there is significant support to show that efficacy predicts engagement, and that individuals and groups with higher levels of efficacy are more engaged in their work.



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As such results lack causation, Salanova et al. (2010) examined longitudinal studies to establish causal and reciprocal relationships between efficacy and engagement. Studies have revealed that a causal and reciprocal relationship exists between ­efficacy and engagement over time. A relationship was also found to exist between efficacy and positive emotions, such as enthusiasm and comfort. Consequently, these were then able to predict engagement. Based on supporting evidence for gain spirals between efficacy and job performance, Salanova et al. (2010) predicted the existence of gain spirals between efficacy and engagement. Perceptions of capabilities arise from mental processes by which employees draw conclusions about their skills and abilities for the achievement of a particular goal. Employees tend to examine how much effort will be required prior to deciding whether or not they will accept the task, challenge, or goal at hand and initiate a specific task. Self-efficacy beliefs play a pivotal role in employees’ perceptions of job demands and job resources. Higher levels of self-efficacy may lead to the viewing of job demands as challenges rather than obstacles, creating a stimulating work environment where employees become highly engaged. In a reciprocal relationship, higher levels of efficacy result in higher levels of engagement, and higher levels of engagement result in higher levels of efficacy.

Broaden-and-Build Theory: Positive Emotions and Engagement The Broaden-and-Build Theory was developed by Barbara Frederickson in 1998, around the time the field of positive psychology began to emerge. Frederickson’s theory focused on the role of positive emotions and their effect on humans. This theory supports that positive emotions exist, not only in the present but over time, and they have a cumulative effect, in a sense supporting health and well-being. Examples of positive emotions— joy, interest, contentment, pride, and love—allow the individual to flourish and build personal resources that are physical, intellectual, social, and psychological. Frederickson contends that positive emotions “broaden the scopes of attention, cognition, and action and that they build physical, intellectual, and social resources” (Frederickson, 2001). The results of multiple longitudinal studies provide empirical evidence to build this theoretical framework. It was found that job resources generate positive emotions. In addition, positive emotions have an effect on personal resources, such as self-efficacy and task persistence. In addition, meditation practices promote positive emotions that result in increased personal resources. Ultimately, through the Broaden-and-Build Theory processes, there is a progression toward becoming more self-­efficacious and resilient, which, in turn, creates positive emotions. Upward gain spirals are therefore accomplished, and well-being is promoted in the present and for the future. There is sufficient evidence to support a reciprocal relationship between work engagement and positive emotions. As a positive affective-emotional state, an initiative of positive outcomes and the outcome of positive emotions, work engagement has been linked to personal resources, which, in turn, are linked to positive emotions substantiating findings of a reciprocal relationship (Salanova et al., 2010).

CORE CONCEPTS As evidenced in the previous theory descriptions, there are several concepts that are embedded within work engagement theories. Some of these concepts transcend a number of the theories (e.g., meaningfulness, vigor), whereas others are specific to one theory (e.g., job resources, absorption).

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RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS THEORY Work engagement has been widely studied across disciplines. Schaufeli et al. (2002) examined the relationship between engagement and burnout in groups of university students and employees of private and public companies. The results supported that engagement and burnout are negatively correlated. Luthans and Peterson (2002) surveyed a group of managers and their subordinates through a random selection from the Gallup Leadership Institute. This study found that managers’ effectiveness and levels of self-efficacy positively correlate to subordinates’ levels of engagement. A study by Langelaan, Bakker, van Doornen, and Schaufeli (2006) explored whether or not engagement could be differentiated from burnout based on personality and temperament. It found that engagement is positively linked to low levels of neuroticism while burnout is linked to high levels of neuroticism. In another study, participants who accessed a Canadian leadership and training website were surveyed regarding the role of meaningful work relative to engagement, burnout, job satisfaction, organizational commitment, and turnover intentions. The study found that meaningful work was positively associated with work engagement (Fairlie, 2011). Reio and Sanders-Reio (2011) examined relationships between workplace incivility and engagement among computer services industry employees and supervisors. This study did not link workplace incivilities to meaningfulness; however, incivilities had a negative impact on safety and availability.

Discriminant Ability of Work Engagement Hallberg and Schaufeli (2006) proposed that in order for work engagement to be considered a valid contribution, it would need to have discriminate ability; that is, the “ability to discriminate against other, adjacent constructs must be established” (p. 119). Therefore, they examined the contextual differences between engagement and other related concepts, including involvement and commitment. Results indicated that work engagement is a separate and distinct construct from other theoretically adjacent constructs, specifically, job involvement and organizational commitment, although there is a greater relationship between work engagement and organizational commitment than between work engagement and job involvement. Correlations to health complaints (or lack thereof), job and personal characteristics, and turnover intentions provide uniqueness for the concept of work engagement. These findings are supported by Christian, Garza, and Slaughter (2011), who conducted a meta-analysis of more than 90 work engagement studies and identified that the concept of engagement was distinct from other concepts such as organizational commitment, job satisfaction, and involvement. Work engagement has also been shown to be distinct from workaholism, a related concept (Schaufeli, Taris, & Van Rhenen, 2008). Engaged employees differ from workaholics in their ability to disengage from work. Even when they are not at work, workaholics remain focused on work, which becomes an obsession. While engaged employees work hard; have high levels of energy denoting vigor; and are dedicated, involved, and enthusiastic; they are not obsessed with work, and they do not demonstrate the same compulsive drive as workaholics (Bakker, Schaufeli, Leiter, & Taris, 2008).

Drivers of Work Engagement There is an abundance of research linking personal resources and job resources to work engagement. The research also supports that engaged employees perform better than nonengaged employees (Bakker & Demerouti, 2008). Examples of job resources



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cited in the literature include performance feedback, collegial and managerial social support, autonomy, supervisory coaching, innovative climate, social climate, job control, information, and opportunities for learning and the acquisition of varied skills. Job resources reduce job demands and associated stress, assist in the achievement of goals, and promote personal and professional growth (Bakker & Demerouti, 2008; Hakanen, Bakker, & Schaufeli, 2006; Schaufeli & Bakker, 2004). Intrinsic and extrinsic motivations resulting from job resources ultimately result in a greater willingness to invest oneself in the task at hand, to achieve organizational goals while simultaneously satisfying basic human needs with feelings of competence and belonging. Personal resources are those resources that reflect perceptions of one’s own abilities related to control over the work environment. Positive perceptions of self have been shown to predict work engagement and improve performance and job satisfaction (Bakker & Demerouti, 2008). Personal resources such as self-efficacy, organizational-based self-esteem, optimism, and resilience have all been found to predict or foster engagement. Higher levels of self-efficacy are indicative of an employee’s willingness to face challenges, resulting in an ability to meet job demands successfully. Optimistic employees typically have a positive attitude and expect good results, while those with higher levels of organizational self-esteem believe that working in the organization will satisfy their needs. “Engaged workers often experience positive emotions, including happiness, joy and enthusiasm; experience better health; create their own job and personal resources; and transfer their engagement to others” (Bakker & Demerouti, 2008, p. 215). Employees who exhibit those personal resources of self-efficacy, organizational-based self-esteem, and optimism will have a greater sense of control and will experience work-related well-being (Xanthopoulou, Bakker, Demerouti, & Schaufeli, 2009). Harter, Schmidt, and Keyes (2002) reviewed Gallup studies that examined wellbeing in the workplace and its relationship to business outcomes. Based on the research, they argued that the well-being of employees warrants attention and is in the best interest of employers, organizations, and communities. It is recognized that employees seek more than tangible benefits; they are searching for meaningful work and opportunities for growth and development. Employers who communicate expectations well to employees and provide employees with the necessary resources to perform their jobs will realize greater employee engagement. It is believed that such employer behaviors generate positive emotions in employees and are reflective of credibility and trust. Failure to meet the basic needs of employees for meaningful work and opportunities for growth and development will result in their becoming bored and disillusioned. Careful selection and recruitment of potential candidates also play an important role in organizational success. Finding a good person–job fit will ensure that employees have the opportunity to do what they enjoy and do best and feel they are contributing to the success of the organization. Wollard and Shuck (2011) identified 42 antecedents to engagement and suggested that organizations should consider antecedents as precursors to engagement. Antecedents were categorized into two categories: individual and organizational. Individual antecedents are those constructs or strategies rooted in employee engagement; organizational antecedents are strategies, structures, or systems necessary to support employee engagement. Individual antecedents supported by empirical evidence are absorption, dedication, higher levels of corporate citizenship, involvement in meaningful work, a link between individual and organizational goals, perceived organizational support, vigor, work/life balance, core self-evaluation, and value congruence.

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Other individual antecedents include being available to engage, coping style, curiosity, emotional fit, motivation, employee/work/family status, feelings of choice and control, optimism, self-esteem, self-efficacy, and willingness to direct personal energies. Organizational antecedents supported by empirical evidence include authentic corporate culture, clear expectations, corporate social responsibility, job characteristics, job fit, level of task challenge, manager expectations, manager self-efficacy, perception of workplace safety, positive workplace climate, rewards, supportive organizational culture, and use of strengths. Those unsupported by empirical evidence are encouragement, feedback, hygiene factors, job control, leadership, mission and vision, opportunities for learning, and talent management. Organizational antecedents that drive engagement “revolve around basic employee/human needs” (Wollard & Shuck, 2011, p. 435).

RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS Nursing is viewed as a science and an art whereby nurses promote health and wellness while reducing the burden of illness (McEwen & Wills, 2002). Nursing’s four global metaparadigm concepts (person, health, environment, and nursing) are recognized as central to nursing conceptual frameworks. They are also relevant to engagement theory and can be conceptualized within the theoretical framework for this research in a broader sense. The concept of person refers to the physical, intellectual, biochemical, and psychosocial needs of the individual. Health, the level of wellness experienced by the client, involves unity of mind, body, and soul. Promoting health for the individual is paramount in care delivery and requires a significant investment—emotional, physical, intellectual, and spiritual—from each nurse. Engagement theory offers a foundation for nurses to become fully engaged in their work, exhibiting vigor, dedication, and absorption. The environment addresses external conditions and significant others that have an impact on a person’s reality. The practice environment, in which care is both delivered and received, is instrumental in accomplishing goals, both for the patient and for the caregiver. Environments that promote empowerment and autonomy will ultimately create an engaged workforce that is prepared to meet the needs of the individual and to deliver care in a holistic manner. Previously in this chapter, engagement was linked to reciprocal relationships and gain spirals with personal resources and job resources. Personal resources are associated with physical, psychological, social, or organizational aspects of work and are fundamental to a person’s ability to achieve work goals. Job resources are the physical, social, or organizational aspects of work. When such resources are not present, job demands may become overwhelming and exceed a person’s potential to meet such demands, which in turn may lead to burnout, the antithesis of engagement. The caregivers’ ability to promote health for self, others, and the community can be linked to personal and job resources. “Nurses subscribe to common values and beliefs, including respect for persons, caring, autonomy of persons, health promotion, illness prevention, professional competence, and ethical conduct” (Monti & Tingen, 1999, p. 27). It is a balance of resources



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that facilitates the ongoing ability for nurses to gain knowledge, skills, and expertise; to create an interface between theory and practice as they provide care in a manner that is congruent with and encompasses the metaparadigm concepts (McEwen & Wills 2002). As a profession, nursing has a unique knowledge base that prepares nurses to discern and address the needs of the individual. Engagement theory and its theoretical concepts, vigor, dedication, and absorption, while not based in nursing, are applicable across disciplines and vital to support nursing performance.

THEORY ANALYSIS Theory analysis for this research study was conducted using Fawcett’s evaluative criteria (Fawcett, 2005). The theory has been used to describe levels of work engagement across a variety of disciplines nationally and internationally. The theory relates to and addresses the research hypothesis, although unstated in the research, that there is a directional relationship between staff nurse engagement and nurses’ levels of self-efficacy. The theory articulates that self-efficacy as a personal resource is related to levels of work engagement, making it a good fit for this research. Fawcett’s evaluative criteria are listed in Table 12.1. Work engagement theoretical concepts (vigor, dedication, and absorption) are closely linked to job demands and job resources, which significantly impact levels of work engagement. The theory focuses on the relationships between job resources, including personal resources such as self-efficacy and job demands, and thus was the driver for the research questions, which examine relationships between three concepts. Additionally, they seek to examine the relationships between work engagement and self-efficacy, which is aligned with the theoretical foundation. Work engagement theory is oriented to outcomes that are critical in patients in that work engagement has been linked to customer satisfaction, productivity, and organizational success (Fairlie, 2011; Harter, Schmidt, & Keyes 2002; Simpson, 2009). For this study, there were existing valid and reliable tools that had been used nationally and internationally. Work engagement was measured using the UWES, which was developed by Schaufeli and colleagues (Schaufeli et al., 2002). This is a self-report, nine-item questionnaire that measures the three underlying dimensions of work engagement, vigor, dedication, and absorption (three questions each). The General Self-Efficacy Scale (GSES) was designed for use in the general adult population (Scholz, Gutiérrez-Dona, Sud, & Schwarzer, 2002) and measured nurses’ levels of self-efficacy. The purpose was to obtain a general sense of the participants’ perceived level of self-efficacy. General self-efficacy reflects how well an individual copes with daily life stressors or adversity and has the ability to accomplish tasks.

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING The theory of work engagement, which provides a framework to examine nurses’ levels of engagement and to develop engagement-enhancing strategies, is not specifically a nursing theory. It is, however, a theory that is applicable across disciplines, and it has been applied to multiple professions and adapted accordingly. Throughout history, nursing research has incorporated and adapted theoretical frameworks

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Table 12.1 Evaluative Criteria and Work Engagement Theory Used in the Study Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

The theory provides a theoretical foundation to examine work engagement, creating a good fit for the research study in that the study examined the relationship among work engagement, self-efficacy, and perceived alternative employment opportunities.

2.

Is it readily operationalized?

Yes, the theory is readily operationalized as the key concepts of work engagement (vigor, dedication, and absorption) are defined and measurable.

3.

How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it relates?

Each concept of the theory can be scored independently and has the ability to explain related phenomena. It has been used to describe and explain relationships between engagement and burnout among private and public company employees (Schaufeli et al., 2002); the ability of engagement to empirically separate from job involvement and organizational commitment (Hallberg & Schaufeli, 2006); and the relationship between engagement and customer satisfaction, loyalty, profitability, productivity, turnover, and safety (Harter, Schmidt, & Hayes, 2002). Work engagement has been shown to predict financial returns (Xanthoupoulou, Bakker, Demerouti, & Schaufeli, 2009); to enhance job performance and organizational commitment to the reduction of turnover intentions (Christian et al., 2011; Hakanen, Schaufeli, & Aloha, 2008; Saks, 2006). It has also been used to predict service climate (Salanova, Agut, & Piero, 2005) and teachers’ organizational commitment (Hakanen, Bakker, & Schaufeli, 2006).

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

The theory addresses the research hypotheses in describing and explaining staff nurses’ perceptions of levels of engagement.

5.

Does the theory flow from the research question?

Yes, the theory flows from the research question. The theory supported exploring staff nurses’ levels of work engagement.

6.

Does the theory address the primary and secondary research questions?

The theory addresses relationships between engagement and self-efficacy; a personal resource presented in the theoretical framework.

7.

Are the assumptions congruent with the assumptions that are made for research?

The assumptions are congruent with the research in that the theoretical foundations are put forth such that there is a relationship between work engagement and self-efficacy.

8.

Is the theory oriented to outcomes that are critical to patients?

The theory supports that work engagement is linked to job performance. As such, it becomes critical to patients, since nurses play an integral role in care delivery and nurses’ performance is a determinant of outcomes (Fairlie, 2011; Harter, Schmidt, & Keyes, 2002; Simpson, 2009).

9.

Are tools available to test relationships of the theory or do they need to be developed?

For this study, two instruments were selected to examine the relationship between work engagement and self-efficacy. The UWES (Schaufeli et al., 2002) was selected to measure work engagement and the GSES (Schloz et al., 2002) measured self-efficacy.

Source: Fawcett, 2005.



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from other disciplines. In the latter half of the 20th century, when nursing knowledge began to emerge as more than just a science, three trends were noted: the use of theories borrowed from other disciplines, the development of conceptual frameworks defining nursing, and the development of middle range theory linked to practice. As nursing scientific knowledge evolved, so too did the belief that nurses require a broad knowledge base that encompasses varied patterns of knowing (Chinn & Kramer, 2004). This broadened perspective on nursing, gained from theory development, research, and reflective practice, catapulted nursing from an occupation to a profession and eventually elevated nursing to an equal footing with medicine and other health care disciplines (Walker & Avant, 2011). In doing this research study, it was noted that multiple studies have examined various aspects of work engagement among nurses. In one of the largest studies ever conducted on nurse engagement, it was found that only 26% of nurses were engaged in their work (Advisory Board Company, 2007). Laschinger and Finegan (2005) conducted a study to examine the relationship between work conditions and staff nurses’ mental and physical health. The study surveyed 500 Canadian nurses employed in urban teaching hospitals to test a model linking structural empowerment to six areas of work life assumed to be precursors to engagement. Other Canadian studies that examined the effect of empowering work conditions on nurses’ engagement and their ability to be effective at work involved groups of new graduate and experienced nurses selected from the College of Nurses of Ontario registry list (Laschinger, Wilk, Cho, & Greco, 2009). A study of nurses’ individual characteristics, job features, and work engagement was conducted in Spain with a sample of 412 nurses, nurse managers, and certified nursing assistants working in a variety of units and divisions. It showed that job stressors were related to resources; for example, workload (Jenaro, Flores, Orgaz, Begoña, & Cruz, 2010). Acute care staff nurses attending a national conference in the United States were surveyed to examine levels of and relationships between self-­transcendence and work engagement. Surveys returned by the 99 participants showed that nurses who had the ability to self-transcend were more likely to have higher levels of engagement (Palmer, Quinn Griffin, Reed, & Fitzpatrick, 2010). ­Bjarndottir (2011) conducted a qualitative study to examine how nurses viewed work engagement in stressful environments. Among the 10 registered nurse participants, it was found that engagement increased when there was positive adaptability, the job was meaningful, the nurse understood personal limits, the nurse was resilient, and there was mutual support. Another study (Rivera, Fitzpatrick, & Boyle, 2011) surveyed 510 nurses working in a large urban academic university center, focusing on nurses’ perceptions of drivers of engagement and work engagement. Findings of the study showed that self-esteem and satisfaction that comes from being a nurse and doing nursing work had the greatest influence on nurses’ engagement. Such studies reflect a shift from more nursing-specific theories toward the changing health care environment. Health care is becoming aligned with the corporate world. Organizational trends in health care have mimicked those of successful industries where performance is measured in scorecards, and outcomes are p ­ ublicly reported. Self-efficacy, one of the key variables in the current research study, is also not a nursing theoretical framework. However, it has been a focus of a number of nursing research studies. Lee and Ko (2010) surveyed nearly 2,000 Korean nurses to examine the influence of self-efficacy and affectivity (individual-level variable) and collective

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self-affectivity (group variable) on hospital nurses’ performance. Results of the study support that there is a strong correlation between self-efficacy and nursing performance. Duggleby, Cooper, and Penz (2009) examined general self-efficacy and its relationship to hope, spiritual well-being, and global job satisfaction among 64 continuing care assistants in Canada. In this study, self-efficacy was significantly and positively correlated to hope. Qualitative results indicated that hope plays a role in work engagement, job satisfaction, and the provision of good care, indicators of job performance and self-efficacy. Chang, Li, Wu, and Wang (2010) surveyed 314 nurses in Taiwan to examine the relationship between job satisfaction and specific personality traits including proactive personality, optimism, self-esteem, self-efficacy, and negative affectivity. This study supports that optimism and self-efficacy predict job satisfaction. In contrast, a study conducted by Chang, Wang, Li, and Liu (2011) examined depression and its relationship to two personality traits among Taiwanese nurses: self-efficacy and optimism. In this study, more than half of the nurses surveyed suffered from mild to moderate depression. Higher levels of self-efficacy are linked to lower levels of depression.

USE OF THE THEORY IN THIS RESEARCH The purpose of this research was to examine relationships among staff nurse engagement, self-efficacy, and perceived alternative employment opportunities. Extensive research has been conducted on work engagement, and it has been identified as a key driver for overall organizational success (Saks, 2006). When measuring organizational success in a large tertiary hospital, one must consistently examine nurse turnover and vacancy rates, customer experience, quality outcomes, and, ultimately, profit margins. A constant balance must be achieved within the care delivery model to ensure adequate resources; safe, high-quality care; and a balanced budget. Existing research on employee engagement conducted across a wide spectrum of industries has captured the interest of the health care industry. As health care continues to change, with organizations facing unprecedented fiscal challenges, such as value-based purchasing and bundle payments, an engaged workforce becomes paramount to success. Positive correlations exist between employee engagement, employee satisfaction, and the customer experience. Engagement is also linked to safety, profitability, productivity, and retention (Fairlie, 2011; Harter, Schmidt, & Keyes 2002; Simpson, 2009). “Empirical evidence suggests that the presence of high levels of employee engagement is also thought to enhance job performance, task performance, and organizational citizenship behaviors, productivity, discretionary effort, affective commitment, continuance commitment, levels of psychological climate, and customer satisfaction” (Wollard & Shuck, 2011, p. 430). It is important to understand that the theoretical framework used for this research study could not be limited in its scope to work engagement. As previously discussed, engagement is a complex concept. It is interdependent with a variety of concepts and can be understood in the context of several theories. In addition, the theoretical framework for engagement must be considered in the context of personal resources and job demands. Therefore, for the purpose of this study, self-efficacy is as significant as engagement, both conceptually and theoretically. Self-efficacy is the core concept in Social Cognitive Theory, discussed earlier. Once again, while this is not a specific nursing theory, it is applicable across disciplines. According to Bandura (1977), “An efficacy expectation is the conviction that



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one can successfully execute the behavior required to produce the outcomes” (p. 193). ­Efficacy expectations differ from outcome expectations in that, despite holding the belief that certain actions will produce specific outcomes, those who do not believe they have ability to accomplish associated tasks will not attempt those actions. Therefore, outcome expectations do not necessarily influence behavior. L ­ evels of self-­efficacy impact perceptions of task capabilities and determine whether or not a person has the necessary coping skills to tackle a given project. Perceived barriers include fear of failure and intimidation. Those persons with higher levels of efficacy will exert greater effort even when they perceive the situation as challenging. Consequently, there is a resultant reinforcement in perceptions related to one’s own efficacy. However, efficacy beliefs alone do not substantiate acceptance of tasks; adequate incentives must also be present (Bandura, 1977). Bandura outlines four sources of efficacy expectations: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. Personal accomplishments play a pivotal role in determining levels of efficacy. As one achieves sustained successes, one is more likely to feel self-efficacious and accept even tougher challenges while coping effectively with occasional failures. The building of self-­ efficacy becomes generalizable to similar events and, to a lesser degree, even to tasks that differ from those that are more familiar. Efficacy expectations are also gained from vicarious experiences. As one watches others perform threatening activities without untoward outcomes, the belief that one can have similar successes is reinforced. Efficacy beliefs achieved from vicarious experiences that depict clear consequences tend to be effective in increasing levels of selfefficacy. Verbal persuasion, perhaps the easiest source, builds self-efficacy and changes beliefs by the power of suggestion and social persuasion. A combination of social persuasion and resources creates greater potential for success and personal competence. However, verbal persuasion alone is somewhat limited in that efficacy can easily vanish in the face of unsuccessful experiences. The final source, emotional arousal, is a physiological response to a stressful or threatening situation. Depending on how stressful one perceives the situation, coping may become impeded by high anxiety and fear. Schaufeli et al. (2002) posits that work engagement has three characteristics: vigor, dedication, and absorption. Vigor shows high energy and investment in work; dedication is manifested by enthusiasm and pride; and absorption is the ability to be fully engrossed. Kahn’s (1990) work on engagement presents three psychological conditions: psychological meaningfulness, psychological safety, and psychological availability. Meaningfulness is derived from autonomous work where employees feel they have the opportunity to use existing abilities while continuing to build new skills. Safety allows an employee to take risks and accept challenges without fear of reprisal. Availability is the ability to invest oneself in work free from distractions resulting from self-consciousness and a lack of self-confidence, both of which suppress engagement. These work engagement definitions have close associations with Bandura’s theoretical framework for self-efficacy and also with the Salanova et al. (2010) work on gain spirals. The theoretical frameworks presented in this chapter support the findings in this research, which found that work engagement is significantly and positively correlated with self-efficacy; in addition, regression analysis showed that self-efficacy was a predictor for work engagement. This study also found that five demographic variables—number of years as a registered nurse, years at the hospital, years in current position, age, and education—did not significantly impact the outcomes for work engagement.

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RECOMMENDATIONS FOR FURTHER RESEARCH As the health care industry undergoes unprecedented change, hospitals are forced to embark on a new era and embrace new possibilities. While the future of health care continues to evolve, nurses will assume a greater role in the provision of care, and those with higher levels of self-efficacy are more likely to engage in their work. ­Recommendations of the 2010 Institute of Medicine (IOM) report The Future of N ­ ursing: Leading Change, Advancing Health provide the basis for advancing n ­ ursing knowledge, skills, and competencies as we prepare to face future health care ­challenges. Key messages from the IOM report are ● ● ● ●

Nurses should practice to the full extent of their education and training. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States. Effective workforce planning and policy making require better data collection and an improved information infrastructure.

In the move from volume-driven to value-driven health care, organizations and nursing leadership are compelled to examine practices that may not serve as well in the future as they have in the past. In the current reimbursement model, organizations will be paid based on quality outcomes and patient satisfaction. Nurse leaders will be forced to seek out new methods to recruit, train, and retain nurses. With a severe nursing shortage on the horizon (American Association of Colleges of Nursing [AACN], 2012), and the anticipated retirement of many in the current nursing workforce, it is essential to actively engage staff nurses in their work. Finding ways to improve the work of clinicians will allow organizations to keep pace with rapid changes in care delivery. As the largest group of employees in many health care delivery systems, nurses are an organization’s greatest asset. Organizations that invest in nurses’ continuing education and ensure appropriate competencies increase nurses’ levels of self-­ efficacy through gain spirals. Building strong orientation and education programs, such as nurse residency programs, will allow nurses to practice to their full scope and become equal partners with other disciplines in providing quality care to patients. Despite the fact that this study supports previous research, which shows that work engagement is positively correlated with self-efficacy, further research is necessary to establish causation between work engagement; personal resources, including selfefficacy; and organizational outcomes. It is also imperative to explore the relationship between an engaged workforce and organizational outcomes. While existing research supports organizational gains as a downstream effect of engaged employees, there remains a lack of clear understanding on the causes of employee engagement. It is widely accepted that personal resources and job resources impact levels of engagement. However, little is known regarding whether or not engaged employees can be selected for employment based on identification of personal resources, such as self-efficacy. Organizations that capitalize on self-efficacy development and gain spirals, whether through successful screening, continuing education, advancing competencies, or through offering developmental workshops, will outperform the competition and ultimately reap the benefits of a more engaged workforce. Magnet designation



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has successfully elevated the profession of nursing in health care facilities across the nation and internationally. It has quantified the value of nursing, raising the standards for quality outcomes, patient experiences, and nurse satisfaction. While perhaps unintentional, there is a significant alignment between Magnet criteria and performance, with Centers for Medicare and Medicaid reimbursement strategies related to nursing sensitive indicators. Examples include patient experience, patient falls, hospitalacquired pressure ulcers, central line infections, and catheter-associated urinary tract infections, to list but a few. Facilities that enjoy Magnet status typically have lower turnover and vacancy rates, are more likely to attract the best nursing candidates, and are less likely to be impacted by the impending nursing shortage. To mitigate the impending nursing shortage, organizations will benefit by exploring new care delivery systems, practice models, and affiliations with nursing colleges and universities. These actions will create competitive advantage that will equip them to meet the needs of the populations and communities they serve. As health care moves from a focus on illness to a focus on wellness and prevention, education will be the catalyst for successful change. Therefore, our ability to effectively create an engaged workforce, as well as to mentor and develop future educators, will be paramount to safe quality health care delivery.

SUMMARY This chapter explained the varying views of work engagement put forth as theoretical frameworks by experts in the field of psychology, including Kahn, Schaufeli, Maslach, and Leiter. Work engagement has been defined as the antithesis of burnout and linked to job resources, personal resources, and job demands. As a global concept, work engagement has been studied across multiple disciplines and in a variety of settings. It is an intriguing concept in that many researchers seek to understand why some employees experience greater levels of engagement than others and organizations with higher levels of engagement among employees tend to experience more desirable outcomes. However, further studies are needed to demonstrate causality between the concept of work engagement and concepts believed to impact ­levels of engagement.

REFERENCES Advisory Board Company. (2007). Engaging the nurse workforce: Best practices for promoting exceptional staff performance. Washington, DC: Author. American Association of Colleges of Nursing (AACN). (2012, August 6). Nursing shortage. Retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage Bakker, A., Demerouti, E., Hakanen, J. J., & Xanthoupoulou, D. (2007). Job resources boost work engagement, particularly when job demands are high. Journal of Educational Psychology, 99(2), 274–284. Bakker, A. B., & Demerouti, E. (2007). The job demands resource model: State of the art. Journal of Managerial Psychology, 22(3), 309–328. Bakker, A. B., & Demerouti, E. (2008). Towards a model of work engagement. Career Development International, 13(3), 209–223. Bakker, A. B., Schaufeli, W. B., Leiter, M. P., & Taris, R. W. (2008). Work engagement: An emerging concept in occupational health psychology. Work & Stress, 22(3), 187–200.

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Part II  Theories Applied to Research Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. Bjarnadottir, A. (2011). Work engagement among nurses in relationally demanding jobs in the hospital sector. Nordic Journal of Nursing Research & Clinical Studies / Vård i Norden, 31(3), 30–34. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&A N=2011366606&site=ehost-live Chang, Y., Li, H. H., Wu, C. M., & Wang, P. C. (2010). The influence of personality traits on nurses’ job satisfaction in Taiwan. International Nursing Review, 57, 478–484. Chang, Y., Wang, P. C., Li, H. H., & Liu, Y. C., (2011). Relations among depression, self-efficacy and optimism in a sample of nurses in Taiwan. Journal of Nursing Management, 19, 769–776. Chinn, P. L., & Kramer, M. K. (2004). Integrated knowledge development in nursing (6th ed). ­Philadelphia, PA: Mosby. Christian, M., Garza, A. S., & Slaughter, J. E. (2011). Work engagement: A quantitative review and test of its relations with task and contextual performance. Personnel Psychology, 64(1), 89–136. doi:10.1111/j.1744-6570.2010.01203.x Demerouti, E., Bakker, A. B., Nachreiner, F., & Schaufeli, A. B. (2001). The job demands-resources model of burnout. Journal of Applied Psychology, 86(3), 499–512. doi:10.1037//00219010.86.3.499 Duggleby, W., Cooper, D., & Penz, K. (2009). Hope, self-efficacy, spiritual well-being and job ­satisfaction.JournalofAdvancedNursing,65(11),2376–2385.doi:10.1111/j.1365-2648.2009.05094.x Fairlie, P. (2011). Meaningful work, employee engagement, and other key employee outcomes: Implications for human resource development. Advances in Developing Human Resources, 13(4), 508–525. doi:10.1177/1523422311431679 Fawcett, J. (2005). Criteria for evaluation of theory. Nursing Science Quarterly, 18, 131. Fredrickson, B. L. (2001). The role of positive emotions in positive psychology. American ­Psychologist, 56(3), 218–223. Hakanen, J. J., Bakker, A., & Schaufeli, W. (2006). Burnout and engagement among teachers. Journal of School Psychology, 43(1), 495–513. Hakanen, J. J., Schaufeli, W., & Aloha, K. (2008). The Job Demands–Resources Model: A threeyear cross-lagged study of burnout, depression, commitment, and work engagement. Work and Stress, 22(3), 224–241. Hallberg, U. E., & Schaufeli, W. B. (2006). “Same same” but different? Can work engagement be discriminated from job involvement and organizational commitment? European Psychologist, 11(2), 119–127. doi:10.1027/1016-9040.11.2.119 Harter, J. K., Schmidt, F. L., & Hayes, T. L. (2002). Business-unit-level relationship between employee satisfaction, employee engagement, and business outcomes. A meta-analysis. Journal of Applied Psychology, 87(2), 268–279. Harter, J. K., Schmidt, F. L., & Keyes, C. L. (2002). Well-being in the workplace and its relationship to business outcomes: A review of the Gallup Studies. In C. L. Keyes & J. Haidt (Eds.), Flourishing: The positive person and the good life (pp. 205–224). Washington, DC: American Psychological Association. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from: http://www.iom.edu/Reports/2010/The-Future-of-Nursing-LeadingChange-Advancing-Health.aspx Jenaro, C., Flores, N., Begoña Orgaz, M., & Cruz, M. (2010). Vigour and dedication in nursing professionals: Towards a better understanding of work engagement. Journal of Advanced Nursing, 67(4), 865–875. doi:10.1111/j.1365-2648.2010.05526.x Khan, W. A. (1990). Psychological conditions of personal engagement and disengagement at work. Academy of Management Journal, 33(4), 692–724.



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Langelaan, S., Bakker, A. B., van Doornen, L. J. P., & Schaufeli, W. B. (2006). Burnout and work engagement: Do individual differences make a difference? Personality and Individual Differences, 40(3), 521–532. doi:10.1016/j.paid.2005.07.009 Laschinger, H. K. S., & Finegan, J. (2005). Empowering nurses for work engagement and health in hospital settings. Journal of Nursing Administration, 35(10), 439–449. Retrieved from http:// search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2009069006&site=ehost-live Laschinger, H. K. S., Wilk, P., Cho, J., & Greco, P. (2009). Empowerment, engagement and ­perceived effectiveness in nursing work environments: Does experience matter? Journal of Nursing Management, 17(5), 636–646. doi:10.1111/jnm.2009.17.issue-5 Lee, T. W., & Ko, Y. K. (2010), Effects of self-efficacy, affectivity and collective efficacy on nursing performance of hospital nurses. Journal of Advanced Nursing, 66(4), 839–848. doi:10.1111/j.1365-2648.2009.05244.x Luthans, F. (2002). Positive organizational behavior: Developing and managing organizational strengths. Academy of Management Executive, 16(1), 57–72. doi:10.5465/AME.2002.6640181 Luthans, F., & Peterson, S. J. (2002). Employee engagement and manager self-efficacy. Journal of Management Development, 21(5), 376–387. Maslach, C., & Leiter, M. P. (1997). The truth about burnout: How organizations cause personal stress and what to do about it. New York, NY: Wiley. McEwen, M., & Wills, E. M. (2002). Theoretical basis for nursing. Philadelphia, PA: Lippincott, Williams and Wilkins. Monti, E. J., & Tingen, M. S. (1999). Multiple paradigms of nursing science. In W. K. Cody (Ed.), Philosophical and theoretical perspectives for advanced nursing practice (4th ed., pp. 27–41). Sudbury, MA: Jones and Bartlett Publishers. Palmer, B., Quinn Griffin, M., Reed, P., & Fitzpatrick, J. J. (2010). Self-transcendence and work engagement in acute care staff registered nurses. Critical Care Nursing Quarterly, 33(2), 138–147. doi:10.1097/CNQ.0b013e3181d912d8 Reio, T. G., & Sanders-Reio, J. (2011). Thinking about workplace engagement: Does supervisor and coworker incivility really matter? Advances in Developing Human Resources, 13(4), 462–478. doi:10.1177/1523422311430784 Rivera, R. R., Fitzpatrick, J. J., & Boyle, S. M. (2011). Closing the RN engagement gap: Which drivers of engagement matter? Journal of Nursing Administration, 41(6), 265–272. doi:10.1097/NNA.0b013e31821c476c Saks, A. M. (2006). Antecedents and consequences of employee engagement. Journal of Managerial Psychology, 21(7), 600–619. doi:10.1108/02683940610690169 Salanova, M. A., Agut, S., & Piero, J. M. (2005). Linking organizational resources and work engagement to employee performance and customer loyalty: The mediation of service climate. Journal of Applied Psychology, 90(6), 1217–1227. Salanova, M. A., Schaufeli, W. B., Xanthoupoulou, D., & Bakker, A. (2010). The gain spirals of resources and work engagement. In A. Bakker & M. P. Leiter (Eds.), Work engagement: A handbook of essential theory and research (pp. 118–131). New York, NY: Psychology Press. Schaufeli, W. B., & Bakker, A. B. (2004). Job demands, job resources, and their relationship with burnout and engagement. Journal of Organizational Behavior, 25(3), 293–315. Schaufeli, W. B., Bakker, A. B., & Salanova, M. (2006). The measurement of work engagement with a short questionnaire: A cross-national study. Educational and Psychological Measurement, 66(4), 701–716. doi: 10.1177/0013164405282471 Schaufeli, W. B., Salanova, M., González-Romá, V., & Bakker, A. B. (2002). The measurement of engagement and burnout: A two sample confirmatory factor analytic approach. Journal of Happiness Studies, 3(1), 71–92. Retrieved from http://search.ebscohost.com/login.aspx? direct=true&db=a9h&AN=11308475&site=ehost-live

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Part II  Theories Applied to Research Schaufeli, W. B., Taris, T. W., & Van Rhenen, W. (2008). Workaholism, burnout and engagement: Three of a kind or three different kinds of employee well-being? Applied Psychology: An International Review, 57, 173–203. Scholz, U., Gutiérrez-Dona, B., Sud, S., & Schwarzer, R. (2002). Is general self-efficacy a universal construct? Psychometric findings from 25 countries. European Journal of Psychological Assessment, 18(3), 242–251. Simpson, M. R. (2009). Predictors of work engagement among medical-surgical registered nurses. Western Journal of Nursing Research, 31(1), 44–65. doi:10.1177/0193945908319993 Walker, L. O., & Avant, K. C. (2011). Strategies for theory construction in nursing (5th ed.). Upper Saddle River, NJ: Prentice Hall. Wollard, K. K., & Shuck, B. (2011). Antecedents to employee engagement: A structured review of the literature. Advances in Developing Human Resources, 13(4), 429–446. doi: 10.1177/1523422311431220 Xanthoupoulou, D., Bakker, A. B., Demerouti, E., & Schaufeli, W. B. (2009). Work engagement and financial returns: A diary study on the role of job and personal resources. Journal of Occupational and Organizational Psychology, 82(1), 183–200.

chapter 13

Sexuality in Women: Theoretical Perspectives Vicki Cleary, Aileen Burton, and Josephine Hegarty

Altered female sexuality is a legitimate concern for all health care professionals, as sexuality is an integral part of a woman’s health and well-being. A key methodological challenge in advancing sexuality research is the lack of a suitable conceptual framework to underpin the research. The purpose of this chapter is to propose and present a conceptual framework for the study of female sexuality from a holistic perspective based on the work of Woods (1984, 1987). Nancy Fugate Woods is a professor of nursing and has a long record of research relating to women’s health issues. In her earlier writings, she provided a multidimensional view of sexuality: “Sexuality pervades human beings, influencing their self-images and feelings. It influences their relationships with others. In addition, sexuality involves the biologic basis for experiencing sexual pleasure, giving and receiving sexual pleasure, and is a powerful force in a person’s ability to bond to another person” (1984, p. 3). This definition of sexuality encompasses numerous elements, including how people feel about themselves, their relationships with others, and the experience of giving and receiving pleasure through physical acts of a sexual nature.

BASIC DESCRIPTION OF THE THEORIES In her writings, Woods described the many influences on a person’s sexuality, including stressful life events such as illness and hospitalization, and she outlined the negative effect that these can have on a woman’s image of herself, social relationships, and sexual functioning (Woods, 1984). Woods (1987) further expands on her views of sexuality. In this article, Woods refers to the complex phenomenon of sexuality and links sexual self-concept, sexual relationships, and sexual functioning diagrammatically to indicate proposed relationships among the three key elements of sexuality. According to Woods, the nursing profession is concerned with “human responses to actual and potential health problems” (1984, p. 117). Thus, when addressing the issue of sexuality with patients, nurses are concerned with patient’s sexual health.

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Therefore, sexuality and sexual health are inextricably linked; that is, an alteration in sexuality leads to altered sexual health. She proposed that the components of this holistic expression of sexuality are also identified in the World Health Organization’s (WHO; 1975) definition of s­ exual health. The WHO define sexual health as the “positive integration of the somatic, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication and love” (p. 6), which serves to give further strength to Woods’s representation of sexuality. However, Woods (1987) did not publish extensive details regarding the origins of her writings pertaining to sexuality. It may be reasonable to assume that she drew upon the elements of the WHO (1975) definition of sexual health; however, this is not explicitly stated. According to Woods (1987), sexual function, sexual self-concept, and sexual relationships are inextricably linked, and any alteration in one element will automatically cause subsequent alterations in the remaining two elements, resulting in a complete change in sexual health. She believes that sexuality is a multidimensional construct and much more than the physical aspect of sexual intercourse, on which the medical literature so often concentrates. As previously stated, Woods encompasses a holistic approach toward sexuality. In addition, sexual functioning as proposed by Woods (1987) includes the biological aspects of sexuality as outlined by Bernhard (1995). Similarly, sexual self-concept as proposed by Woods is inclusive of body image and femininity, as suggested by Bernhard. However, Woods’s illustration of sexuality incorporates the important aspect of sexual relationships that is neglected by Bernhard. The work of Kralik, Koch, and Telford (2001) on women and sexuality also correlates with Woods (1987); here the authors described sexuality as beginning with the individual and extending to women’s relationships with others, and it included how they felt as sexual beings. Relationships included friendships, emotional intimacy and love, and/or sexual activities. This further explains that sexuality is much more than a physical activity, as it incorporates many factors that can affect a woman’s daily life. Woods’s representation of sexuality has not been further expanded upon since its initial development in 1987. In addition, for Woods’s (1987) diagrammatic illustration of sexuality to be of benefit to researchers in the area of sexuality, further extrapolation is required. For example, as Woods does not offer explicit guidance on what is encompassed in a sexual relationship, how would a researcher go about investigating this phenomenon? Therefore, further development of her representation of sexuality has been undertaken by the authors of this chapter, and it is this work that will be described in the following section. While the main focus of the exemplars behind the framework in this chapter relate to a cancer diagnosis in women, the framework can also be applied in other contexts, such as living with a chronic illness (Burton, Coates, & McLaughlin, 2013), which is detailed in Case Study 2 of this chapter.

CORE CONCEPTS Woods’s (1987) diagrammatic representation of sexuality encompasses three inter­ related elements: sexual self-concept, sexual relationships, and sexual functioning. This representation of sexuality was further developed through various methods— a comprehensive literature review (Cleary & Hegarty, 2011), quantitative research (Cleary, Hegarty, & McCarthy, 2011), and qualitative research (Cleary, Hegarty,



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Figure 13.1  Conceptual framework of sexuality in women with gynecologic cancer. SEXUAL SELFCONCEPT Body image Sexual esteem Feminine identity and gender role

SEXUALITY SEXUAL RELATIONSHIPS Intimacy Communication

SEXUAL FUNCTIONING Sexual response cycle: - Desire - Arousal/lubrication - Orgasm

Based on an amalgam of empirical and theoretical literature published by Kaplan (1979), Woods (1987), Price (1990), Andersen (1999), Hughes (2000), and Tierney (2008).

& McCarthy, 2013) to provide a more inclusive, broader picture of the construct of sexuality in the context of women with a diagnosis of gynecologic cancer (see ­Figure 13.1).

Sexual Self-Concept Woods (1987) refers to sexual self-concept as, “The image one has of oneself as a man or a woman and the evaluation of one’s adequacy in masculine or feminine roles. Sexual self-concept also includes body image, reflecting the abstract representation of one’s body and the evaluation of that image against personal and cultural standards” (p. 1). Drawing from the above definition, Cleary and Hegarty (2011) suggest that women’s sexual self-concept is made up of three dimensions: (a) body image, ­ (b) feminine identity and gender role, and (c) sexual esteem. The “self-concept” has formed the basis of much debate in the disciplines of psychology and sociology since the end of the 19th century. In particular, these debates center on the meaning of “self” and “self-concept.” No unified definition of the term self-concept exists in the literature; it is often used interchangeably with other “self”-related terms such as ­self-identity, self-esteem, self-regard, and self-acceptance. The beginning of the debate on self-concept was led by the writings of William James (1890), whose distinction between the “I” and the “me” formed the foundation of the “self” literature and has since been considered a pioneer in the area of self-concept writings (Harter, 1996). James proposed that, “a man’s self is the sum total of all that he can call his” (p. 291). According to Harter, James proposed that the self was composed of the “I,” which is believed to be the “knower,” and the “me,” which is regarded as what is known. Psychologists have termed the “me” self as the

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“self-concept.” James believed that the “self” was a hierarchical system composed of numerous dimensions. For him, these dimensions included a material self, a social self, and a spiritual self (Epstein, 1973). The social self referred to by James (1890) was related to other people’s judgments about the person (Epstein, 1973). This notion of other people’s views related to constructing self-concept was further developed from a sociological perspective by Cooley (1902) and Mead (1934). First, Cooley introduced the idea of the “looking glass self,” in which people’s conception of themselves is influenced by their perceptions of the opinions of others (Wells & Marwell, 1976). Mead concurred with this position and stated that “the self is something which has a development; it is not initially there at birth, but arises in the process of social experience and activity, that is, develops in the given individual as a result of his relations to that process as a whole and to other individuals within that process” (p. 135). Therefore, for Cooley and for Mead, a person’s self-concept was formed through his or her interactions with others. Numerous behavioral scientists built on the works of James (1890), Cooley (1902), and Mead (1934) to further develop the idea of “self-concept.” Through a review of the works of these scientists (Hilgard, 1949; Lecky, 1945; Rogers, 1951; Sarbin, 1952; Snygg & Combs, 1949; Sullivan, 1953), Epstein (1973) proposed that self-concept had various defining features. In particular, he suggested that the self-concept is a hierarchical structure that is composed of various dimensions; it is dynamic, alters with experience, and develops though social interactions. Similarly Shavelson, ­Hubner, and Stanton (1976) proposed a model of self-concept that was multidimensional and hierarchically structured. This model purports that global self-concept at the top of the hierarchy is relatively stable, but as one descends the hierarchy, self-concept divides into different dimensions and subsequently becomes less stable. In this model, selfconcept was viewed both as an outcome and as a mediator to explain other outcomes (Marsh & Hattie, 1996). In addition, Shavelson et al. (1976) believe that self-concept includes both a descriptive element and an evaluative element. They provide the example “I am happy” (descriptive) and “I do well in mathematics” (evaluative) (Shavelson et al., 1976, p. 108). This evaluative component of the self is commonly referred to as “self-esteem.” The descriptive element has also been referred to as the content component, that is, those characteristics that are subject to evaluation (Katz, Rodin, & Devins, 1995). In addition, Foltz (1987) and Curbow, Somerfield, Legro, and Sonnega (1990) are in agreement with the proposition that self-concept is a malleable construct that is at risk of alteration along the cancer and treatment trajectory. Foltz suggests that the self-concept is comprised of various dimensions including a body image dimension and a sexual dimension. Curbow and colleagues support this idea and suggest that when examining the self-concept of patients, it may be beneficial to examine a specific dimension of self-concept that has relevance for a particular cancer population rather than self-concept in its global form, thus highlighting the importance of dimensions such as sexual self-concept. As previously outlined, self-concept is a multifaceted structure consisting of a core self-concept and many dimensions (Curbow et al., 1990; Epstein, 1973; Shavelson et al., 1976). Sexual self-concept is considered by many to constitute one of these aspects of the self (O’Sullivan, Meyer-Bahlburg, & McKeague, 2006; Rostosky, Dekhtyar, Cupp, & Anderman, 2008; Spiegel, 2008; Vickberg & Deaux, 2005; Woods, 1987). According to Vickberg and Deaux (2005), a dearth of research exists on this important concept. Andersen and Cryanowski (1994) propose that a cognitive



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understanding of one’s sexual self would have the potential to add an essential component to the study and understanding of other sexuality-related factors such as attitudes and behaviors. From a review of the key writings of authors in the field of the “self” and “self-concept” (Cooley, 1902; Epstein, 1973; James, 1890; Mead, 1934; Shavelson et al., 1976), it is evident that self-concept is a dynamic, cognitive conception with various components. One of these components pertains to the concept of “sexual self-concept” as proposed by Woods (1987). Woods proposes that sexual self-concept encompasses various aspects, such as body image and an “evaluation of one’s (sexual) adequacy.” Cleary and Hegarty (2011) suggest that this evaluation referred to the concept of “sexual esteem.” In the following section, self-esteem in its broadest sense will be defined, followed by an analysis of sexual esteem in a cancer context.

Sexual Esteem Self-esteem is a component of self-concept as indicated by numerous authors (Campbell, 1990; Cast & Burke, 2002; Curbow et al., 1990; Gecas, 1982; Greenwald, Bellezza, & Banaji, 1988; Katz et al., 1995; Wells & Marwell, 1976). In Wells and Marwell’s (1976) synthesis of the literature pertaining to self-esteem, they state that, similar to selfconcept, no uniform definition of self-esteem exists in the literature. They propose that “self-conception is generally depicted in terms of reflexive attitudes, which in turn are usually considered to have three key aspects—cognitive (the psychological content of the attitude), affective (a valuation attached to this content), and conative (behavioural responses to the attitude). Self-esteem is commonly identified with the second of these aspects” (p. 231). This is in agreement with the historical writings of Cooley (1902), who asserted that a key element of the self was related to a form of feeling (Harter, 1996). It is commonly accepted that self-concept refers to “cognitive” aspects of the self, whereas self-esteem relates to an evaluation of these cognitive aspects (Campbell, 1990; Curbow et al., 1990). Within a cancer context, Schain (1980) proposes that self-esteem “is the sum total of all a person feels about himself/herself” (p. 16), thus reinforcing the idea that self-esteem is associated with a personal evaluation. James (1890) was the first writer to highlight self-esteem as an affective concept (Mruk, 1999). James suggests that self-esteem is formed from an examination of successes in comparison to aspirations. Mruk interpreted James’s writings on selfesteem to suggest that self-esteem is “affective” [emphasises feeling], “competenceoriented” [it depends on the effectiveness of one’s actions], and “dynamic” [open to change]” (p. 16). Drawing on this work, Rosenberg (1965) suggests that self-esteem is also concerned with “worthiness.” Coopersmith (1967) and Branden (1969) reinforce these ideas and provide definitions of self-esteem that incorporate components of feelings/evaluation, worthiness, and competence. Branden proposes that self-esteem is the “integrated sum of self-confidence and self-respect” (p. 110). In summary, by examining the works of the leading writers in the area of self-esteem, it is evident that self-esteem is composed of three central components: it is formed through an evaluation of one’s competence and worthiness, it is the affective component of self-­ concept, and it is a dynamic concept that is subject to fluctuations (Cast & Burke, 2002; Mruk, 1999). Rosenberg (1965) was the first writer in the area of self-esteem to suggest that it can be further divided into two forms: global self-esteem and specific self-esteem.

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According to Rosenberg, Schooler, and Schoenbach (1995), global self-esteem is related to a person’s psychological well-being, whereas specific self-esteem is related to behavior. Swann, Chang-Schneider, and McClarty (2007) suggest that when interested in examining specific outcomes (e.g., sexuality), it is pertinent to study a specific form of self-esteem (e.g., sexual esteem) rather than self-esteem in its global format. This has led to a definition of sexual esteem as “the tendency to positively evaluate one’s capacity to sexually relate to a partner” (Snell & Papini, 1989, p. 261) or “a generalised tendency to positively evaluate one’s own capacity to engage in healthy sexual behaviours and to experience one’s sexuality in a satisfying and enjoyable way” (Snell, 1998, p. 521). In the authors’ opinion, the former definition of sexual esteem provided by Snell and Papini (1989) is limited by its reference to “relating to a partner.” Thus, the latter definition provided by Snell (1998) has more universal appeal and is applicable to women both with and without a partner. A more recent definition of sexual esteem was provided by Wiegerink, Roebroeck, Donkervoort, Stam, and Cohen-Kettenis (2006) who refer to sexual esteem in the context of physical disabilities as a “feeling of sexual acceptance and worthiness” (p. 1027). These definitions highlight that sexual esteem is an important dimension of sexuality that needs to be addressed. This has been recognized in research pertaining to physical disabilities (Wiegerink et al., 2006) and the sexual practices of adolescents (Seal, Minichiello, & Omodei, 1997). In summary, self-esteem is the evaluative component of self-concept; it is dynamic in nature and is concerned with a person’s competence, worthiness, and confidence in himself or herself (Branden, 1969; Coopersmith, 1967; Rosenberg, 1965). Global self-esteem can be further divided into specific forms of self-esteem, one of which is referred to as sexual esteem (Snell, 1998; Snell & Papini, 1989). Numerous authors have made the proposition that global self-esteem is a component of global self-concept; therefore, it is reasonable to suggest that sexual self-concept incorporates the dimension of sexual esteem.

Body Image Body image was also referred to by Woods (1987) as a key component of self-concept. Seminal writers in the area of body image include Schilder (1950), Fisher and Cleveland (1968), and Price (1990). Similar to that of self-concept and self-esteem, the term body image lacks a universal definition (Newell, 1999; White, 2000). Body image has been considered both as a dimension of sexual self-concept and self-concept (Buck, 1984; Curbow et al., 1990; Driever, 1984; Fobair, Stewart, Chang, D’Onofrio, Banks, & Bloom, 2006; Foltz, 1987; Lamb, 1991; Woods, 1987), a dimension of self-esteem (Katz et al., 1995; Schain, 1980), and as a separate entity to all the aforementioned self-related phenomena (Newell, 1999). Body image has also been referred to as a dimension of sexual self-concept by Woods (1987). In addition, the majority of the aforementioned literature acknowledged that body image is a dimension of a broader sense of self. Perhaps the most frequently cited definition of body image in the psychology literature is that provided by Schilder (1950), who suggests that body image is “the picture of our body which we form in our mind, that is to say the way in which our body appears to ourselves” (p. 11). Woods (1987) refers to body image as “reflecting the abstract representation of one’s body and the evaluation of that image against personal and cultural standards” (p. 1). It is widely acknowledged that body image is a subjective concept—the actual appearance of a person’s body may not accurately



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reflect a person’s cognitive image of his or her body (Burt, 1995; Price, 1990; Schilder, 1950; White, 2000). Within a nursing context and particularly within an oncology perspective, Price (1990, 1998) is an accomplished author in the area of body image. He suggests that body image is composed of various dimensions including “perception—the way in which we experience the body, cognition—the ways in which we think of the body, social—the body image as something shared between people and aesthetic—the experience of the body as something attractive or beautiful” (1998, p. 51). Although Newell (1999) highlights that Price’s model of body image has received no empirical support, he does purport that Price’s model of body image deserves appropriate recognition as it emphasizes the importance of body image outside the field of eating disorders in the nursing discipline. White (2000) stresses the complexity of body image and proposes that body image disturbance occurs when there is a discrepancy between objective reality of appearance and the subjective opinion of appearance. Body image is highly subjective and has been linked with both mental and physical health (DeFrank, Bahn Mehta, Stein, & Baker, 2007). According to DeFrank et al. (2007), the many physical changes that occur as a result of cancer and its treatment, including weight loss, hair loss, and scarring, all have the ability to negatively affect a woman’s body image.

Feminine Identity and Gender Role The definition of sexual self-concept provided by Woods (1987) includes “one’s adequacy in masculine or feminine roles,” thus highlighting the importance of femininity and associated roles as a dimension of sexual self-concept. Gender identity has been defined by Woods as “the private or personal experience of one’s maleness, femaleness” (p. 203), thus relating to masculinity or femininity as highlighted in the definition of sexual self-concept provided by Woods. In contrast, gender role has been defined by Palmer (1998) as “. . . masculine and feminine behaviour” (p. 15), thus relating to the masculine or feminine roles outlined in Woods’s (1987) definition of sexual self-concept. Similarly, Burt (1995) proposes that gender identity and sex roles are integral components of sexuality. Therefore, a key dimension of sexual self-­ concept relates to feminine identity and gender role. This is reinforced by Reis, Kizilkaya, and Coskun (2010), who conducted a mixedmethods study (N = 100) that highlighted that gynecologic cancer has the potential to affect what they term gender role (feminine identity), thus legitimizing the inclusion of this dimension in the conceptual framework of sexuality. Therefore, the author ­proposes that the dimensions of feminine identity and gender role encompass the following aspects: feelings of femininity and role as a mother (reproductive ability). This is supported by Southard and Keller (2009), who surveyed 52 men and women with various forms of cancer regarding their perceptions of the meaning of sexuality and found that the ability to feel feminine or masculine and the ability to have children were deemed integral components of sexuality. Feelings of femininity are closely linked to the reproductive organs (Tan, Waldman, & Bostick, 2002). Therefore, any assault on a woman’s reproductive organs has the ability to negatively alter a woman’s femininity (Juraskova et al., 2003). In a grounded theory study that aimed to describe aspects of sexuality important to women after breast cancer treatment, it was found that the effects of treatment were perceived as related to losses: loss of bleeding, loss of sexual sensations, and loss of

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womanhood (Chamberlain Wilmoth, 2001). Women felt that the surgery performed was an assault on their bodies that resulted in loss of sexual organs and identity. They felt their womanhood was taken away and their femininity threatened. Schover (2005) reported that alterations in fertility are a frequent facet of cancer morbidity. Therefore, issues of fertility and reproductive ability are pertinent areas of concern for women with cancer (Thaler-DeMers, 2001). Unfortunately, infertility is a devastating side effect of cancer and its treatment for women in their child bearing years. Infertility can result from the removal of the sexual organs in the case of gynecologic cancer (oophorectomy, hysterectomy) or as a side effect of chemotherapy in cancers such as breast cancer (Krebs, 2006). The ability to reproduce is viewed as a necessity for marriage in some cultures and thus can have an impact on the potential to form relationships (Thaler-DeMers, 2001). In summary, sexual self-concept as proposed by Woods (1987) can be further developed to include aspects of sexuality such as body image and sexual esteem, which were recognized by Cleary and Hegarty (2011). In addition, the previous discussion highlights that feminine identity and gender role is another important dimension of sexual self-concept and incorporates feelings of femininity and associated behavior such as the role of a mother. Alterations in sexual self-concept have the ability to influence the remaining components of sexuality proposed by Woods (1987), including sexual relationships and sexual functioning.

SEXUAL RELATIONSHIPS Sexual relationships are defined as “the interpersonal relationships in which one’s ­sexuality is shared with another” (Woods, 1987, p. 1). Sexual relationships and sexual function are interrelated, with satisfaction in relationships being positively associated with sexual satisfaction (Sprecher, 2002). Following a review of the empirical and theoretical literature, Cleary and Hegarty (2011) suggested that sexual relationships encompassed concerns pertaining to communication and intimacy within relationships.

Communication Open communication within relationships has been recognized as an important variable in the adaptation to a cancer diagnosis (Manne et al., 2006; Morgan, 2009). This was highlighted by Wortman and Dunkel-Schetter (1979), who conducted a theoretical analysis surrounding interpersonal relationships in a cancer context. Wortman and Dunkel-Schetter illuminate the importance of open communication within relationships by suggesting that lack of communication within relationships can often be misinterpreted as disinterest or rejection. Similarly, Manne (1998) and Anllo (2000), who conducted literature reviews surrounding cancer in the marital context and sexual life after breast cancer, respectively, concluded that communication within relationships following a cancer diagnosis is a frequent area of concern. Germino, Fife, and Funk (1995) also report that open communication is a necessity for healthy relationships, but is often lacking in partnerships following a cancer diagnosis. Morgan (2009) drew from research conducted by Manne et al. (2006) to highlight three communication patterns that may arise following a cancer diagnosis: (1) Constructive [“Both partners discuss issues, express feelings, understand each other, and



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feel that issues are resolved”]; (2) Mutual avoidance [“Both partners avoid discussing issues”]; and (3) Demand withdrawal [“One partner wants to discuss and pushes the other partner, who then withdraws”] (p. 67). Manne et al. examined the relationship between these three types of communication patterns, relationship satisfaction, and psychological distress in women with breast cancer (N = 147) and their partners (N = 127) using a quantitative longitudinal design. Not surprisingly, participants who reported engaging in constructive communication reported lower levels of distress and greater relationship satisfaction. These results highlight the importance of open communication within relationships following a cancer diagnosis. Anllo (2000) highlights the difficulties women with breast cancer may experience in discussing issues related to diagnosis and recurrence. Findings of a qualitative study conducted by Holmberg, Scott, Alexy, and Fife (2001) also highlights the lack of communication between partners (N = 5) and women (N = 10) with breast cancer on issues related to grief and potential death. Anllo (2000) suggests that this lack of communication may be due to fear of reinforcing “negative thinking” and evoking distress. Difficulties in communicating about sexual issues have also been highlighted in numerous other studies (Boehmer & Clark, 2001; Kralik, Koch, & Telford, 2001; Rasmusson & Thome, 2008; Van de Wiel, Weijmar Schultz, Wouda, & Bouma, 1990). “Communicating about sexuality” arose as a major theme in a publication that aimed to explore constructions of sexuality from the perspective of middle-aged women suffering from chronic illnesses (Kralik, Koch, & Telford, 2001). Written correspondence from 81 women was analyzed using a descriptive exploratory method to reveal three major themes relating to sexuality. Participants revealed difficulty in communicating the effects of illness on their sexuality to their partners. Boehmer and Clark (2001) suggest that this lack of communication leaves partners isolated when adapting to sexual alterations. Tierney (2008) cautions that it is often hard for couples to broach the subject of sexuality; this lack of communication may be regarded as lack of interest or desire. Communication is necessary to prevent feelings of rejection and disinterest. Tan, Waldman, and Bostick (2002) warn that tension within sexual relationships can result in minor arguments leading to major conflicts.

Intimacy Measurement of intimacy is a fundamental factor in measuring relationship quality as physical, emotional, and psychological health has the potential to be affected by the degree of intimacy within a relationship (Boden, Fischer, & Niehuis, 2010; Hook, Gerstein, Detterich, & Gridley, 2003; Moss & Schwebel, 1993; Ornish, 1998; Schaefer & Olson, 1981; Van den Broucke et al., 1995). As human beings, we live in societies composed of family, friendship, and workplace relationships. These relationships may serve to fulfill our need for intimacy through love and belonging, as represented by Maslow’s (1954) pyramidal representation of an individual’s hierarchy of needs. This particularly applies to the intimacy experienced in committed relationships with a partner (Moore, McCabe, & Stockdale, 1998). According to Timmerman (1991), the concept of intimacy is poorly defined within the literature. Therefore, she endeavored to provide clarity to the concept by conducting a concept analysis. Timmerman proposes that intimacy is “a quality of a relationship in which the individuals must have reciprocal feelings of trust and emotional closeness toward each other and are able to openly communicate thoughts and feelings with each other. The conditions that must be met for intimacy to occur

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include reciprocity of trust, emotional closeness, and self-disclosure.” However, Timmerman does not incorporate the aspect of physical closeness into this definition; in contrast, Moss and Schwebel (1993) concluded that physical closeness was a key element of intimacy. They examined 61 definitions of intimacy in an effort to provide one comprehensive definition, and devised one that was based upon five elements of intimacy: commitment, affective intimacy, cognitive intimacy, physical intimacy, and mutuality. Williams (2001) also suggests that a fundamental aspect of intimacy is physical touch. Feldman, Gowen, and Fisher (1998) and Hook et al. (2003) describe intimacy as a journey one takes with a partner, developing over time, that has trust, personal validation, self-disclosure, and love and affections at its center. According to Laurenceau, Barrett, and Pietromonaco (1998), intimacy is a fundamental component of relationships and includes both the communication of feelings and intimate actions (Van der Riet, 1998). Sinclair and Dowdy (2005) describe it as that feeling of emotional closeness to another that enables sharing of personal feelings together with expectations of understanding, affirmation, and demonstrations of caring. Olson, Olson-Sigg, and Larson (2008) identified the key differences between happily and unhappily married couples using their own validated marital satisfaction questionnaire. They noted that this intimacy is linked to eight relationship elements: communication, conflict resolution, sexual relationships, couple closeness, personal compatibility, couple flexibility, shared spiritual values, and good relationships with extended family and friends. Gender differences also exist in intimacy requirements, with women emphasizing the need for affection, emotional closeness, and sharing of feelings, while men require physical closeness and sexual activity (Hook, Gerstein, & Detterich, 2003; Ridley, 1993). Thus, intimacy in relationships is a key element of sexual relationships that needs to be assessed when examining sexuality in females. “Renegotiation of sexual and nonsexual intimacy after cancer” arose as a key finding during interviews with partners of both women and men with a variety of cancer diagnoses (N = 20) (Hawkins et al., 2009). Findings of this grounded theory study highlighted that participants elevated the importance of intimacy over sexual intercourse following cancer diagnosis. Intimacy was considered by participants to include hugging, kissing, and a general sense of closeness. These intimate practices were considered to be satisfying and enjoyable activities and not just forms of affection that led to sexual intercourse. From the previous discussion, it is evident that important aspects of sexual relationships, including communication and intimacy between partners, can be significantly altered following a diagnosis and treatment of cancer and must be considered by health professionals when addressing sexual issues with cancer patients.

SEXUAL FUNCTIONING Woods (1987) refers to sexual function as “the ability of an individual to give and receive sexual pleasure” (p. 1). In the conceptual framework of sexuality, Cleary and Hegarty (2011) interpreted this definition to include the elements of the sexual response cycle as outlined by Kaplan (1979). The sexual response cycle refers to a sequence of various physical and psychological stages through which a person progresses during sexual activity (Brassil & Keller, 2002; Kaplan, 1979; Masters & Johnson, 1966). It is well recognized within the literature that sexual function incorporates this cycle of events (Brassil & Keller, 2002).



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Masters and Johnson (1966) are renowned as seminal writers in this area since the publication of their classic work, Human Sexual Response. The impetus for this work lay in the desire to explicitly study behavioral reactions to sexual stimulation so that alterations in these reactions could be effectively treated. Subsequently, Masters and Johnson observed the response of adult males and females during a variety of sexual stimulation methods in laboratory conditions. Following these observations, they purported that human sexual response is composed of four linear stages: excitement, plateau, orgasm, and resolution. Within each of these phases numerous physiological changes occur within both the sex organs and other body systems. However, Kaplan (1979) suggests that the sexual response cycle consists of only three stages: desire, arousal/excitement, and orgasm. Woods (1984) states that Kaplan’s triphasic model of the sexual response cycle is useful in understanding the consequences of pathophysiology leading to altered sexual function. Brassil and Keller (2002) state that during the desire phase, sexual thoughts and desires cause a woman to become sexually aroused and leads to the initiation of sexual activity. As a woman enters the excitement phase, various physiological responses occur, such as increased blood flow to the sexual organs, moistening of the vagina, and erection of the nipples. Finally, during the orgasmic phase, a woman experiences contractions of the vagina and uterus, indicating the peak of sexual response. A diagnosis of sexual dysfunction is given to an alteration in any of the stages of the sexual response cycle outlined above. The three key classification systems for female sexual dysfunction used in the literature are the World Health Organization’s International Classification of Diseases (ICD-10, 1994), the Diagnostic and Statistical Manual of Mental Disorders, DSM-5 (5th edition) (American Psychiatric Association, 2013), and the International Consensus Group Definitions (Basson et al., 2004). The ICD-10 classification system describes female sexual dysfunction as the various ways in which a female is unable to participate in a sexual relationship as she would wish. This system of classification is outlined as follows: lack or loss of sexual desire, sexual aversion disorder, failure of genital response, orgasmic vaginismus, nonorganic dyspareunia, and excessive sexual drive. This classification approached sexual function as having psychological and somatic elements but did not examine its medical elements. The Diagnostic and Statistical Manual of Mental Disorders (APA, 2000) outlined nine sexual dysfunction disorders, summarized by Miles et al. (2007) to include sexual desire disorder or decreased libido; sexual arousal disorders; premature, delayed, or absent orgasm following a normal sexual excitement phase; and sexual pain disorders. The DSM-IV-TR classification did examine medical elements but used a psychophysiological approach. This classification system defines it as disturbances in sexual desire and in the psychophysiological changes that define the sexual response cycle and cause a significant marked distress and difficulty for the female (APA, 2000). One of the outcomes here is the level of distress associated with the dysfunction, which is more focused than the broader outcome indicated in the ICD-10 classification. Criticism of the original taxonomy led an International Definitions Committee comprised of 13 experts to propose and publish revised definitions of the classification system of female sexual dysfunctions (Basson et al., 2004). The impetus for this work lay in the belief that the former classification system was based on a linear model of sexual functioning that was predominantly focused on genital sensation. In addition, Basson (2000) proposes that female and male sexual responses are fundamentally different. According to Basson, women, unlike men, are less influenced by the hormone testosterone to engage in sexual intercourse. In addition, women

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do not need to orgasm to derive sexual satisfaction from sexual activities. Basson and c­ olleagues (2004) argue that outside influences such as the need for intimacy and closeness with a partner may prompt the initiation of sexual intercourse rather than sexual desire in the genital sense. Basson felt that women correlated with Masters and Johnson’s (1966) and Kaplan’s (1979) models more readily with new relationships but not when in long-term relationships, where a need for intimacy and not physical gratification was needed. The result is that women have the ability to go from a position of sexually neutral to sexually motivated to satisfy this need for intimacy, satisfaction, love, acceptance, and closeness within their romantic relationships. In addition, age-related changes in sexual desire must be taken into account in any definition on hypoactive sexual desire (Basson et al., 2004). Overall, Basson and colleagues (2004) propose a more holistic view toward classifying sexual dysfunction and underline the need to consider psychosocial factors when treating these dysfunctions. The categories outlined in the DSM-IV-TR were retained in this definition and expanded to include organic causes. This new consensus classification system is based also on the linear model of female sexual response but includes personal distress as an outcome criterion. The marked distress criterion’s existence in the DSM-IV-TR classification and a personal distress criterion in the Basson et al. (2004) classification have caused strong criticism. Few studies have incorporated the distress criterion. Bancroft, Loftus, and Long (2003), in a general population, noted that sexual-related personal distress is not strongly predicted by sexual function problems; instead, it is predicted by emotional well-being and the emotional relationship with a partner. The distress criterion was not present in the DSM-III but was added in the fourth edition. The guidelines for changes to the DSM criteria review state that changes could be made only with empirical research supporting it (APA, 1994). Seagraves et al. (2007) examined the criteria for changing this and noted that only minimal discussion took place. The DSM-IV-TR system was updated through consultation with a group of international experts, extensive literature reviews, and attaining feedback on initial proposals. The revised DSM-5 Sexual Dysfunctions diagnostic criteria and classifications have placed increased emphasis on the potential for both psychological and organic/medical causation for sexual dysfunction and go some of the way to recognizing the relatively common reality of sexual dysfunction presenting as a mixture of impaired desire, arousal, and orgasm (American Psychiatric Association, 2013). According to Tierney (2008), cancers and their treatments have the ability to affect one or more of the phases of the sexual response cycle, leading to a diagnosis of sexual dysfunction. Wilmoth and Spinelli (2000) suggest that poor body image and lowered selfesteem can result in decreased desire in gynecologic cancer patients. Cancer treatments (e.g., chemotherapy) can also alter the levels of circulating hormones (e.g., testosterone) necessary for sexual desire (Wilmoth & Spinelli, 2000). Arousal may be altered due to nerve damage from surgery affecting vasocongestion and lubrication (Katz, 2007). The orgasmic phase of the sexual response cycle can also be affected by nerve damage, in particular damage to the sympathetic nervous system (Wilmoth & Spinelli, 2000). Therefore, sexual function refers to a series of events known collectively as the sexual response cycle (desire, arousal, orgasm) (Kaplan, 1979). Any alteration in each of these events is referred to in the literature as sexual dysfunction (APA, 2000; Basson, 2000; Basson et al., 2004). In summary, the conceptual framework of sexuality developed by Cleary and Hegarty (2011) is based on an amalgam of empirical and theoretical literature (Andersen & Cryanowski, 1994; Hughes, 2000; Kaplan, 1979; Price, 1990; Snell & Papini, 1989; Tierney, 2008; Woods 1987). This framework was developed in a female cancer



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context and received empirical support in a gynecologic cancer population in a previous study conducted by the researcher (Cleary et al., 2011). A number of interrelationships are proposed within the conceptual framework. It is proposed that there is a bidirectional relationship among all three of the major concepts: Sexual self-concept (as operationalized by measurements of body image, sexual esteem, gender role, and feminine identity), sexual relationships (as operationalized by measuring intimacy and communication), and sexual functioning (as operationalized by the sexual response cycle) are interrelated. A decrease in levels of intimacy, poor communication, a decrease in body image, lower sexual esteem, and alterations in feminine identity all impact individually and collectively on sexual functioning and vice versa. Not surprisingly, all dimensions of sexuality were interrelated to varying degrees (Cleary, Hegarty, & McCarthy, 2011). All of these relationships were found to be statistically significant. To summarize, according to Woods (1987), sexual function, sexual self-concept, and sexual relationships are inextricably linked, and any alteration in one dimension will automatically cause subsequent alterations in the remaining two dimensions, thus affecting an individual’s sexual health.

RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS The proposed conceptual framework of sexuality (Figure 13.1) outlines a set of concepts and configures the relationships between the concepts. The four metaparadigm concepts (person, environment, health/illness, and nursing) are an implicit part of the conceptual framework. The framework of sexuality proposed for females in a cancer context places the human experience (the person) as a central tenet in the experience of sexuality. Females, as holistic beings, are unique, dynamic, and responsive multidimensional individuals who are capable of abstract cognitive reasoning, creativity, and aesthetic appreciation. Women are open systems, continually interacting with the changing internal and external environment as well as being a composite of their physiological, psychological, social, and spiritual domains. It is the understanding of sexuality espoused in this conceptual framework that helps individuals to explore their personal meanings of sexuality and to deal with associated changes in the dimensions of sexuality. The environment is the setting that provides the context for the human social experience of everyday life. In the context of sexuality, the environment reflects the importance of relationships, and communication in particular, with sexual partners. Health is a delicate balance between wellness and illness; it is a dynamic representation of the human processes reflective of an individual’s possibilities and his or her realities and is based on caring and feeling cared for. Sexuality is a constituent part of health and well-being; therefore, an optimum understanding of sexuality assists us in maintaining health and well-being. Nursing as an academic discipline and a clinical profession has embraced the art and science of holistic, person-centered care guided by the values of human freedom, autonomy, and accountability (Fawcett, Watson, Neuman, Hinton Walker, & Fitzpatrick, 2001; Mead & Bower, 2000). In this context, the goal of nursing is humanistic enhancement of health potential in human beings. The importance of addressing sexuality within a health care perspective was initially brought to the fore by the WHO (1975). Since then, sexuality has increasingly been recognized worldwide as a legitimate

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concern for health care professionals (Higgins, Barker, & Begley, 2009). The inclusion of sexuality within nursing theories devised by Roy; Watson; and Roper, Logan, and Tierney firmly placed sexuality within the sphere of nursing care (Roper, Logan, & Tierney 2000; Roy, 2009; Watson 1999; White, 2002). This was reinforced by the publication of a sexual health strategy by the Royal College of Nursing (RCN) in 2001. This document states that “sexuality and sexual health are legitimate areas of nursing activity, and that nurses have a professional and clinical responsibility to address them” (RCN, 2001, p. 5), thus highlighting sexuality as a vital facet of holistic nursing care.

THEORY ANALYSIS An analysis of the framework using an evaluative criterion (Fawcett, 1999, 2005) is presented in Table 13.1. Table 13.1 Evaluative Criteria and the Use of the Conceptual Framework on Sexuality in a Female ­Cancer Context Questions for evaluation

1.

Does the theory fit the research that you wish to do?

Responses to questions

The theory focused on describing the various dimensions of sexuality and their relationships with each other. This framework provided a comprehensive, multidimensional view of the dimensions of sexuality that are at risk of alteration following a gynecologic cancer diagnosis. In addition, the conceptual framework of sexuality (Figure 13.1) guided intervention content, thus providing a strong theoretical framework to the intervention, which also ensures a holistic approach to the construct of sexuality. Prior research ­(Cleary, Hegarty, & McCarthy, 2011) had established that women required information relating to all three concepts of sexuality outlined in the conceptual framework of sexuality (sexual self-concept, sexual functioning, and sexual relationships).

2. Is it readily operationalized?

Yes, but in order to operationalize the components of the theory, a review of literature and a qualitative descriptive study assisted with providing the narratives used in the information booklet.

3. How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it relates?

Although Woods’s work was not developed specifically in a cancer care context, her representation of sexuality has been acknowledged by various researchers in cancer-related studies (Bruner & Boyd, 1999; Butler et al., 1998; Gamel, Hengeveld, & Davis, 2000; Lamb, 1991).

4. Does the theory relate to and address the research hypotheses in its description and explanation?

The conceptual framework relates to and addresses the research hypotheses in its description and explanation of the relationship between sexual self-concept, sexual functioning, and sexual relationships.

5. Does the theory flow from the research question?

The theory guided both the research questions asked and the content of the intervention proposed. In addition, the research helped to develop and expand the conceptual framework. Therefore, the theory guided the development of the research question and hypotheses. (continued)



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Table 13.1 Evaluative Criteria and the Use of the Conceptual Framework on Sexuality in a Female ­Cancer Context (continued) Questions for evaluation

6. Does the theory address the primary and secondary research questions? 7.

Responses to questions

The framework has the potential to answer primary and secondary questions relating to female sexuality in a chronic illness context.

The assumptions are congruent with the assumptions that are made Are the assumptions congruent with the assumptions for the research in that (a) there is a directional relationship between that are made for research? sexual self-concept, sexual functioning, and sexual relationships; (b) the dimensions of sexuality are affected by having a gynecologic cancer diagnosis; and (c) nurses should not focus just on sexual functioning but should look at the totality of sexuality as proposed within the framework.

8. Is the theory oriented to outcomes that are critical to patients?

The theory is oriented to outcomes that are critical to patients. It allows for patients’ individual experiences of sexuality or alterations in their sexual self-concept, sexual functioning, and sexual relationships to be addressed by the health care professional.

9. Are tools available to test relationships of the theory, or do they need to be developed?

In a prior study completed as part of an MS, the Body Image Scale (Hopwood et al., 2001) and the Sexual Esteem Scale (Snell & Papini, 1989) were administered to women a minimum of 6 weeks postdiagnosis of any form of gynecologic cancer to measure sexual self-­ concept; the Intimate Relationships Scale (Hetherington & Soeken, 1990) was used to measure sexual relationships; and the Arizona Sexual ­Experiences Scale (McGahuey et al., 2000) was used to measure sexual ­functioning (Cleary & Hegarty, 2011).

Source: Fawcett (1999, 2005).

The philosophical basis of the framework was not made explicit by Woods in her writings. However, one could argue given the utility of the theory in underpinning the development of interventions relating to sexuality that the framework could be considered to fall within the remit of the epistemology of constructionism (as reality is socially constructed) and within the sphere of symbolic interactionism. Different individuals may construct the meaning of sexuality from a situation (illness) in multiple ways, and the individual is an active, reflective participant in the construction of meaning from a situation. The nurse then seeks to gain an understanding of the individual’s interpretations of his or her reality derived from social interactions and interpersonal relationships. Semantic clarity is evident in the constitutive definitions given for the concepts. In addition, the concepts are linked by means of bidirectional propositional relationships between sexual self-concept, sexual relationships, and sexual functioning, indicating the structural consistency of the theory.

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING Woods’s (1987) conceptualization of sexuality has been acknowledged by various researchers in cancer-related studies (Bruner & Boyd, 1999; Butler et al., 1998; Gamel, Hengeveld, & Davis, 2000). Woods proposed a multidimensional view

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of sexuality composed of three interrelated concepts: sexual self-concept, sexual relationships, and sexual functioning. Through an examination of empirical and theoretical literature surrounding sexuality in a female cancer context, Cleary and Hegarty (2011) further developed Woods’s framework of sexuality to create a conceptual framework of sexuality (Figure 13.1). In this framework, sexual function was perceived to include the dimensions of the sexual response cycle (desire and arousal, excitement, and orgasm) (Kaplan, 1979); sexual self-concept was further divided into the dimensions of body image (Price, 1990), feminine identity and gender role (Bernhard, 1995; Turner, 1999), and sexual esteem (Snell & Papini, 1989). Finally, sexual relationships were perceived to include communication (Tierney, 2008) and ­intimacy (Hughes, 2000).

USE OF THE THEORY IN THIS RESEARCH The conceptual framework was used by the authors in a number of studies that will be presented as two separate case studies.

Case Study 1 Cleary, Hegarty, and McCarthy conducted a number of studies relating to sexuality in a gynecologic cancer context. The first study sought to investigate sexual selfconcept, sexual relationships, and sexual functioning, and the relationship between these and certain demographic variables of Irish women following a diagnosis of gynecologic cancer (Cleary, Hegarty, & McCarthy, 2011). Using a descriptive, correlational approach, 106 women with a diagnosis of gynecologic cancers completed various scales: The Body Image Scale, Sexual Esteem Scale, and Sexual Self-Schema Scale to measure sexual self-concept; the Intimate Relationships Scale to measure sexual relationships; and the Arizona Sexual Experiences Scale to measure sexual functioning were administered to women postdiagnosis of any form of gynecologic cancer. Participants reported negative changes in relation to their sexual self-concept, sexual relationships, and sexual functioning. Participants reported negative changes in relation to all stages of the sexual response cycle. Thus, gynecologic cancer has the potential to negatively affect a woman’s sexual self-concept, sexual relationships, and sexual functioning. The second study related to the phased development and testing of an educational intervention focused on sexuality for women with gynecologic cancer (Cleary, McCarthy, & Hegarty, 2012). Intervention development was guided by the Medical Research Council framework for complex intervention development. A phased approach was taken to the design and evaluation of this complex intervention, which included (a) an in-depth literature review, (b) selection of a theoretical framework, (c) a qualitative study, (d) development of intervention content and process, and (e) pilot testing of the intervention. Content of the intervention was guided by the conceptual framework of sexuality. The development of the intervention was preceded by a qualitative study with eight women with gynecologic cancer (Cleary, Hegarty, & McCarthy, 2013). Open-ended interview questions were broadly based on the conceptual framework of sexuality and focused on women’s perception of their sexuality and how gynecologic cancer and associated treatment had influenced this perception. Participants reported distressing alterations in all aspects of their sexuality after diagnosis and treatment.



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In addition, all participants defined sexuality in broader terms than the physical act of sexual intercourse. Participants’ accounts reflected the fact that sexuality is an integral component of a woman’s life and must be acknowledged as such.

Case Study 2 The work of Woods (1987) was used in a sexuality and chronic illness study undertaken by a team of researchers including Aileen Burton (University College Cork, Ireland) in conjunction with Professor Vivien Coates and Dr. Marian McLaughlin (University of Ulster, Ireland) with a focus on women living with diabetes mellitus. Here they expanded and built on the work of Woods’s understanding of sexuality in relation to her three elements (sexual self-concept, sexual relationships, and sexual function) by incorporating the work of Verschuren et al. (2010) through the addition of a fourth element, psychological well-being. According to Verschuren et al., psychological well-being has the potential to impact on sexual function and sexual relationships. In addition, they focused on placing chronic illness at the center of sexuality by identifying the disease activity and its associated complications (Verschuren et al., 2010). The purpose of the study was to examine the sexuality of females with diabetes mellitus and to examine their association with physiological and psychological factors compared to a general female population (Burton, Coates, & McLaughlin, 2013). This study used a quantitative descriptive, correlational survey approach and employed two data collection methods: self-completed surveys (with researcher present) and an online data collection method.

RECOMMENDATIONS FOR FURTHER RESEARCH Sexuality is an important part of a woman’s health and is thus a legitimate concern for health care professionals. Lack of knowledge leading to patient misunderstanding can play a contributory role in causing altered sexuality (Maughan et al., 2002). Therefore, timely and appropriate information is essential to increase patient satisfaction and promote optimum sexual health outcomes (Maughan et al., 2002). The authors recommend that researchers and clinicians consider using the framework in its entirety with patient groups to develop, test, and expand the relationships within the framework. In addition, theory-driven interventions have the potential capacity to help women negotiate the impact of a chronic illness diagnosis and treatment on their sexuality and sexual health.

SUMMARY Sexuality as a multifaceted construct is not easy to define, and it does not have a single meaning outlined within a single theory (Weis, 1998; White & Heath, 2002). Following this, the meaning of sexuality within a female cancer context was explored. It became evident that sexuality is much more than the physical act of sexual intercourse or the ability to reproduce (Thaler de Mers, 2001). A conceptual framework of sexuality (based on the seminal work of Woods [1987] and an amalgam of the literature by Kaplan [1979], Snell and Papini [1989], Price [1990], Andersen [1999], Hughes [2000], and Tierney [2008]) was presented. This conceptualization (Figure 13.1) of sexuality has

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received empirical support as illustrated in the two case studies provided. This framework provides a comprehensive, multidimensional view of the dimensions of female sexuality that are at risk of alteration following an illness. The framework of sexuality is a relevant and suitable framework for health care professionals to use when addressing the concept of sexuality with women during periods of both wellness and illness.

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chapter 14

Acculturation Theory Emerson E. Ea

The concept of acculturation is a frequently described and explored variable in studies about immigration, globalization, immigrant health, and health disparities. As the world becomes more interconnected and as global migration intensifies, there is a need to examine the process of how individuals and groups integrate into a different culture. Acculturation is a challenging concept to define and conceptualize. Many theories and conceptual frameworks have attempted to explain how this procedure occurs and how it influences personal, work-, and health-related outcomes. Berry’s (1980, 1997, 2003) conceptual framework on acculturation is frequently used in exploring this multidimensional idea because it provides a comprehensive model to capture this elusive phenomenon.

BASIC DESCRIPTION OF THE THEORY Sociologists and anthropologists, who tried to understand and explain the process European immigrants undergo in their immigration into the United States, pioneered the research on acculturation. Anthropologist J. W. Powell in 1880 was the first to describe the changes in Native American languages brought about by the influences of European immigrants (Baker, 2011). Early social scientists Redfield, Linton, and Herskovits (1936) defined acculturation as “those phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original culture patterns of either or both groups . . . .” Several other definitions followed over time including one from the Social Science Research Council (SSRC, 1954) that expanded the definition of acculturation to include psychological dimensions such as personality factors, value systems, and roles as important determinants of acculturation. These early conceptualizations suggested a unidirectional nature of acculturation. This hypothesis was thought of as moving toward assimilating into the dominant cultural group and, in the process, resulting in a transformed individual who has adopted the behaviors, traits, and values of the dominant culture. In addition, the

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term acculturation has been used interchangeably with or substituted for other related terms such as assimilation, adaptation, integration, and adjustment. Canadian psychologist J. W. Berry (1980) expanded the concept of acculturation to include several phases and varieties. Berry, who recognized the bidirectional nature of how immigrants adjust in a different culture, is a foremost authority on the topic of acculturation. He argued that immigrants do not necessarily discard their original beliefs and behaviors upon immigration and that acculturation leads to individual as well as group transformations. His early theories of acculturation discussed its complex nature, course, and levels (Berry, 1980). Berry (1980, 1997, 2003) acknowledged that acculturation occurs at group and individual levels. He theorized that this activity is made up of three phases that include contact, conflict, and adaptation. The first phase is the initial contact of two cultures or individuals; without this, acculturation would not be possible. The next phase, conflict, occurs if there is resistance between cultures and individuals; the third and final phase, adaptation, is viewed by Berry as an inevitable process that could be further subcategorized into either positive or negative (Berry, 1980). He also recognized the challenge of understanding the essence of acculturation, and supported the use of instruments that could capture its multifaceted nature.

CORE CONCEPTS Berry (2003) provided a comprehensive model to explain how individuals and groups integrate into a different culture. Major concepts that relate to this theory include adaptations at the individual and group levels, acculturative stress, psychological acculturation, and ethnic identity. J. W. Berry (2003) also referred to the individual and group adaptations as acculturation strategies. These strategies have different terminologies dependent on which groups are being considered. Berry (2003) classified the group and individual acculturation strategies of the nondominant group as assimilation, integration, separation, or marginalization. Assimilation is defined as the process of cultural transformation that takes place when immigrants relinquish their original cultural identities and adopt the attitudes and behaviors of the dominant culture; integration refers to a deliberate technique whereby immigrants maintain their original culture while at the same time adopting the attitudes and behaviors of the dominant culture. Separation pertains to the group’s or individual’s voluntary decision to withdraw from society. Marginalization, on the other hand, is characterized by feelings of alienation among individuals or groups. Marginalization could result from repeated failed attempts to integrate into the dominant culture. Those acculturation strategies of the dominant group or the larger society result in multiculturalism, a “melting pot” society, segregation, or exclusion (Berry, 2003). Multiculturalism implies that the larger or the dominant society welcomes and embraces cultural diversity that also encourages and supports maintenance of the nondominant culture’s original heritage. A melting pot suggests the larger society’s expectations for the acculturating group to relinquish its cultural heritage and adopt the dominant culture’s norms and behaviors. Segregation relates to the separation enforced by the dominant society, and exclusion is the deliberate refusal



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of the larger society to embrace and recognize the acculturating group (Berry, 2003). Several individual responses that influence acculturation were also identified by Berry (1980): level of language proficiency skills; personal flexibility; level of educational attainment; perception of one’s ethnic or cultural identity; specific individual attributes; and the individual’s reactions to the stress that accompanies the process of acculturation. Berry (2003) refers to psychological acculturation to describe individual responses to acculturation. This individualized adaptive process encompasses behavioral changes and acculturative stress. These behavior changes involve changes in attitudes, language, and self-identification. Acculturative stress occurs when the individual encounters difficulties in the adjustment process. According to Berry (2003), those who have successfully integrated into the larger society encounter less stress compared to those who are exposed to marginalization and alienation. This aspect of maladjustment has been associated with several negative outcomes that include psychological and mental distress and the adoption of unhealthy lifestyles such as smoking, use of alcohol, and substance abuse ­(Al-Omari & ­Pallikkathayil, 2008). The procedure of acculturation is also accompanied by a change in peoples’ ethnic identity. This involves how individuals categorize themselves based on culture, phenotype, religion, language, or geographic origin (Berry, 2003). Several factors that influence the immigrant’s perception of ethnic identity have been identified, including language proficiency of the original and/or host culture, social/peer network, length of residency in the host culture, and generational status (Berry, 2003). Berry’s conceptual framework (1980, 1997, 2003) links how cultural/group responses influence the individual acculturation experience. The initial cultural contact serves as the catalyst of this experience. Changes at the cultural level are bidirectional and uneven in nature (i.e., occur in both groups and have a significant influence on how an individual in both cultures/groups adjusts in this process [­ Figure 14.1]). Berry also provides a diagram that outlines the four strategies of acculturation at both the individual and group levels (Figure 14.2). Figure 14.1  A framework for understanding acculturation: cultural and psychological levels. CULTURAL/GROUP LEVEL

Culture A Cultural Changes Contact

Culture A Culture B

Culture B

Source: Berry (2003).

PSYCHOLOGICAL/INDIVIDUAL LEVEL Psychological Acculturation

Adaptation

Individuals in Cultures A and B:

Individuals in Cultures A and B:

Behavioral Shifts

Psychological

Acculturative Stress

Sociocultural

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Part II  Theories Applied to Research Figure 14.2  Four acculturation strategies based on two issues—views of ethnocultural groups (left) and of larger society (right). ISSUE 1: MAINTENANCE OF HERITAGE CULTURE AND IDENTITY

Integration

ISSUE 2: RELATIONSHIPS SOUGHT AMONG GROUPS

Separation

Assimilation

Marginalization

Multiculturalism

Melting Pot

Segregation

Exclusion

STRATEGIES OF ETHNOCULTURAL GROUPS

STRATEGIES OF LARGER SOCIETY

Source: Berry (2003).

Figure 14.3  A framework for acculturation research. INDIVIDUAL LEVEL VARIABLES

GROUP LEVEL Society of Origin

Moderating Factors Prior to Acculturation

• Political Context • Economic Situation • Demographic Factors

• Age, Gender, Education, Pre-acculturation • Status, Migration Motivation, Expectations • Cultural Distance (Language, Religion, etc.) • Personality (Locus of control, Flexibility)

Group Acculturation • Physical • Biological • Economic • Social • Cultural

Society of Settlement • Attitudes • MC Ideology • Ethnic Attitudes • Social Support • Large Society • Ethic Society Source: Berry (1997).

Acculturation Experience

Appraisal of Experience

Strategies Used

Immediate Effets

Long-Term Outcomes

Life Events

Stressors

Coping

Stress

Adaptation

Moderating Factors During Acculturation • Phase (length of time) • Acculturation Strategies: Attitudes & Behaviors • Coping: Strategies & Resources • Social Support • Societal Attitudes: Prejudice & Discrimination



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Illustrated in Figure 14.3, Berry (1997) supplies a comprehensive framework of how to best examine acculturation. Key variables at the cultural/group and individual levels are identified. The variables that influence groups and individuals prior to that initial cultural contact are outlined in the top boxes. The factors that affect individuals and groups during the activity of acculturation are shown in the middle and bottom boxes. This diagram suggests that acculturation is a dynamic, multifaceted experience moderated by intrinsic and extrinsic factors. Most importantly, this framework provides researchers with a guide as to which variables to address when testing the theory.

RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS THEORY The disciplines of anthropology, psychology, and public health have used Berry’s model extensively to explore the process of acculturation and its effect on individuals and groups. This broad multidimensional concept has been well explored in the social sciences and education research. An area that has currently become significant in the study of acculturation is the relationship of acculturative stress to health outcomes. There is a growing literature that attempts to establish a link between a­ cculturation and major health and health-related outcomes such as hypertension, obesity, depression, and use of alcohol (Alegria et al., 2008; Allen et al., 2008; Choi, Rankin, Stewart, & Oka, 2008; Lasseter & Callister, 2009; Steffen, Smith, Larson, & Butler, 2006; Zemore, 2007). There is evidence in the literature suggesting that a higher level of acculturation is associated with poor health outcomes, also termed as the immigrant paradox (Alegria et al., 2008; Allen et al., 2008; Choi et al., 2008; Lasseter & Callister, 2009; Steffen et al., 2006; Zemore, 2007). A methodological issue that has critical implications in advancing the science of acculturation is the apparent lack of instruments that fully capture the essence of acculturation. This occurs despite the wide prevalence of acculturation devices in the literature. This paradox is related to the varying viewpoints on the process of acculturation regarding the nature and direction of acculturation as either a unidimensional or bidirectional operation. A unidimensional model posits that acculturation occurs in a linear manner (i.e., immigrants move toward assimilation); a bidirectional activity reflects a bicultural identity, whereby immigrants adopt the traits and behaviors of the dominant culture while at the same time maintaining their cultural heritage (Berry, 2003). Cabassa (2003) classified the different types of acculturation measures as either unidimensional or bidirectional—the two theoretical perspectives from which they were derived. He also stated that single-proxy measures such as language use, length of residency in the host culture, and multivariate tools based on the unidimensional model lack depth and are inadequate to measure acculturation. Although complex, the use of instruments that reflect acculturation as a bidirectional process would be best to use to shed light on the multidimensional nature of this elusive concept (Cabassa, 2003). Examples of the many devices that attempt to measure acculturation include A Short Acculturation Scale for Hispanics (ASASH); Bidimensional Acculturation Scale (BAS); Acculturation Rating Scale for Mexican Americans–Revised (­ ARSMA-II); and A Short Acculturation Scale for Filipino Americans (ASASFA).

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RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS The discipline of nursing has evolved to continuously integrate knowledge from other disciplines to further enrich its knowledge and scientific base, as well as enhance its status as a significant contributor in advancing individual and population health. Berry’s model has been used by nurse researchers to understand how individuals adjust to a new culture and how it influences immigrants’ personal, work-, and health-related outcomes. Although Berry did not explicitly discuss how his theory pertains to the nursing metaparadigm concepts, this hypothesis addresses the person, environment, and health. Berry describes the individual as a participant in the process of acculturation. There are several outcomes at a personal level as a result of the procedure of acculturation. The individual could integrate, assimilate, separate, or withdraw. The single person is an open system that is influenced by intrinsic and extrinsic factors. The environment serves as the laboratory where the dynamic process of acculturation takes place. According to Berry (2003), the technique of acculturation does not only result in individual transformations but it also leads to changes in cultures or groups participating in the process. Acculturation is also associated with periods of stress that have been shown to profoundly impact physical and mental health among immigrants.

THEORY ANALYSIS Fawcett (2005) provided a framework to evaluate nursing theories. The criteria include significance, internal consistency, parsimony, testability, empirical adequacy, and pragmatic adequacy. This design was used to analyze acculturation (Table 14.1). As immigration continues to intensify and as our conceptions of globalization continue to evolve, the significance of understanding how individuals and groups adapt to a different culture is important. The conceptual structure developed by Berry (1997) is a helpful guide to exploring and comprehending this complex phenomenon. The theoretical configuration clearly shows the interrelationships among the core concepts of the proposition at the individual and group/cultural levels. The definition is explicitly stated, well explicated, and for the most part used consistently by the author. The concept of acculturation is difficult; this is reflected in the many components of Berry’s theoretical framework. The definitions of the concepts are clear and comprehensive. Several instruments have been developed to capture the essence of this elusive hypothesis. Examples of these tools include ASASFA, BAS, and the Stephenson Multigroup Acculturation Scale (SMAS). There is ample evidence in the literature supporting the empirical adequacy of Berry’s theory on acculturation. This idea has been tested in nursing practice. Understanding the implications of this concept is beneficial when providing culturally sensitive care, especially among the immigrant population. In addition, comprehending the interrelationships of the different facets of this theory has significance in designing health interventions that could lead to positive health and health-related outcomes.



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Table 14.1 Evaluative Criteria and Use of Theory of Acculturation in a Study Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

The theory developed by Berry (2003) provides a comprehensive framework that could be used to capture the major constructs of acculturation. Berry’s theoretical structure was used in a study to examine how immigrant nurses adjust in a different culture (Ea et al., 2008, 2010).

2.

Is it readily operationalized?

As acculturation is a complex concept, the researcher needs to clearly state the research questions and identify the concepts to be measured.

3.

How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it relates?

Berry’s theory on acculturation has been extensively used in social sciences and public health to describe and explain how immigrants adjust to a different culture.

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

The theory is able to relate to and address the research hypotheses in its description and explanation of how immigrants integrate into a different culture.

5.

Does the theory flow from the research question?

Berry’s theory could be used to explore research questions that relate to how immigrants integrate into a different culture. It could also be used to explain the diverse adaptation strategies that individuals and groups use in their process of cultural adjustment and how these influence personal, work-related, and health-related outcomes.

6.

Does the theory address the primary and secondary research questions?

The theory addresses the primary and secondary research questions (i.e., to determine if there was a relationship between acculturation and job satisfaction among Filipino registered nurses [RNs] who are working in the United States).

7.

Are the assumptions congruent with the assumptions that are made for research?

The assumptions of the theory are congruent with the assumptions that are made for this particular research. The research question, which was to determine the relationship between acculturation and job satisfaction among Filipino RNs working in the United States, reflected the purported influence of this immigration experience on a personal and work-related outcome.

8.

Is the theory oriented to outcomes that are critical to patients?

The theory is oriented to outcomes that are critical to immigrants’ adjustment that could have personal, work-related, and health-related outcomes.

9.

Are tools available to test relationships of the theory or do they need to be developed?

A multitude of instruments in the literature have been developed to measure acculturation. This speaks to how important this concept is in our multicultural society. Examples of the tools that have been developed include A Short Acculturation Scale for Filipino Americans (ASASFA), Bidimensional Acculturation Scale (BAS), and Stephenson Multigroup Acculturation Scale (SMAS).

Source: Fawcett (2005).

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RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING No nursing theory specifically focuses on acculturation. Rather, this concept is integrated in major transcultural nursing theories. Transcultural nursing theorist Madeleine Leininger (Leininger & MacFarland, 2002) mentioned acculturation, especially how it relates to health and health-related outcomes, in her Theory of Transcultural Nursing as “the process by which an individual or a group from culture A learns how to take on many of the behaviors, values, and lifeways of culture B.” Several other nursing scholars, such as Andrews and Boyle (2011), who specialize in cultural studies, suggested that acculturation is voluntary and synonymous with assimilation, whereas Spector (2004) explicitly defined acculturation as an involuntary process. Nursing research that relates to acculturation often cites Berry’s conceptual framework. These nursing studies cover a range of topics that include the relationship of acculturation between immigrants’ health behaviors and status, as well as perceptions of quality of life (Al-Omari & Scheibmeir, 2009; Buscemi, Williams, Tappen, & Blais, 2012; Kim, Ashing-Giwa, Singer, & Tejero, 2006; Lee, 2012). Al-Omari and Scheibmeir (2009) investigated the relationship between use of tobacco and acculturation among Arab Americans. Results of the study revealed a positive relationship between smoking and the level of acculturation among the study participants. Lee (2012) also explored the relationship between acculturation and the health status of Arab Americans. The conclusions of this exercise indicated that biculturalism is associated with better physical health, and that better mental health is related to participants’ attraction to the U.S. culture. Buscemi et al. (2012) conducted a secondary data analysis to explore the relationship between acculturation and health among Hispanic American older adults. Study results revealed that those who were more acculturated reported better ­mental—but not physical—health status. Acculturation was measured using the Cross-Cultural Measure of Acculturation; in addition, SF-8™ was used to measure the participants’ health status. Kim et al. (2006) explored the relationship between Asian American breast cancer survivors’ health-related quality of life and acculturation. Results of this study indicated an association between the two variables, when sociodemographic, medical, and health-access factors were controlled. There have also been a number of investigations that focus on the immigrant nurses’ adjustment experience and how this influences their perception of quality of life, personal contentment, and job satisfaction. The majority of these studies have been conducted in the United States and other developed countries that have become magnet destinations for registered nurses (RNs) coming from economically disadvantaged countries in Asia, Africa, and the Caribbean (Brush & Berger, 2002; Ea, Quinn Griffin, L’Eplattenier, & Fitzpatrick, 2008; Ea, Itzhaki, Ehrenfeld, & Fitzpatrick, 2010). Results of these nursing evaluations revealed that the process of acculturation among international nurses is complex and multidimensional regardless of the length of residence in host societies. Studies on acculturation of new and long-term immigrant nurses showed common and recurring themes including overcoming internal and external stresses at the initial phase; negotiating cultural differences; and modifying one’s values, behaviors, and personality over time. However, although themes on acculturation of new and long-term immigrant nurses are similar, findings of this research also suggest that length of residence in host societies is a major determinant



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on how one views work and life in general (Daniel, Chamberlain, & Gordon, 2001; DiCicco-Bloom, 2004; Ea et al., 2008; Ea et al., 2010; Magnusdottir, 2005; Xu, 2007; Yi & Jezewski, 2000). .

USE OF THE THEORY IN THIS RESEARCH The assumptions of Berry’s model were used by the author to identify three stages that immigrant nurses experience in their process of adjustment in a different culture (Ea, 2007): cultural contact, cultural negotiation or bargaining, and cultural adjustment. Stage of Cultural Contact. This step begins when immigrant nurses leave their countries of birth for employment abroad and is similar to Berry’s phase of initial contact between two different cultures (Berry, 1980). This period is characterized by feelings of excitement and wonderment as immigrant nurses experience a new culture. However, it is also characterized by feelings of uneasiness as they become aware of the complexities of living and working in a different culture. They struggle to learn work-related tasks and become aware that their preimmigration expectations of living and working in a diverse culture are unrealistic. The literature has suggested that the discrepancy between expectations and actual work and life experiences of newly immigrated nurses could lead to job dissatisfaction and frustrations (Daniel et al., 2001; Withers & Snowball, 2003). Stage of Cultural Negotiation or Bargaining. This second phase is analogous to Berry’s (1980) stage of conflict, where immigrant nurses attempt to blend into the culture of their host countries. It is a time when they become acutely aware of the disparity between their personal beliefs and values and their host culture’s ideals. Many may perceive alienation and discrimination from coworkers and patients during this period, as they navigate how to live successfully in a different culture. Immigrant nurses have to make an important conscious decision to adopt and learn the behaviors, attitudes, and skills of their host culture. Those who are unable to adjust may leave their jobs and return to their countries of origin, typifying Berry’s negative adaptation (Berry, 1980). Stage of Cultural Adjustment. This phase is characterized by a time of transformations in the attitudes, behaviors, and personalities of immigrant nurses who have become comfortable living in a different culture. It is similar to Berry’s (1980) positive adaptation phase. The author used Berry’s model as a guide to investigate the relationship between acculturation and job satisfaction among Filipino RNs in the United States. Findings of this study showed that Filipino RNs surveyed had an acculturation level that leaned toward the American culture and had a moderate level of job satisfaction; further, there was a moderate correlation between the acculturation and job satisfaction among this sample. Survey outcomes also revealed that acculturation, length of U.S. residency, and age significantly predicted satisfaction for these nurses (Ea et al., 2008). In another investigation, the author, along with international colleagues, aimed to determine the levels of, and the difference in, acculturation of Former Soviet Union (FSU) nurses in Israel and Filipino RNs in the United States (Ea et al., 2010). The collaborators of this research project used ASASFA to measure acculturation among the participants in the United States, and modified it for their counterparts in Israel. Study results showed that Filipino RNs had an acculturation level that leaned toward

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the American culture, whereas FSU nurses had an acculturation level that was closer to their original culture than that of Israel. There was a significant difference in acculturation between these two groups of immigrant nurses.

RECOMMENDATIONS FOR FURTHER RESEARCH Acculturation is a fertile area of research in nursing. There is a need to develop valid and reliable multidimensional instruments to accurately capture this complex phenomenon. The discipline of nursing should also intensify its efforts to collaborate with other social science researchers in exploring this phenomenon. Nurses’ clinical background and personal experiences in caring for the immigrant and culturally diverse population could be valuable in understanding and clarifying this complex topic. Nursing as a holistic discipline is in a pivotal position to design a disciplinespecific theoretical framework that views acculturation in the context of nursing practice. There is also a need to explore and clarify the relationship between acculturation and health outcomes. Berry’s theoretical structure provides a helpful guide to test this relationship. Understanding this process could assist nurses in achieving culturally sensitive interventions when caring for the immigrant population. In addition, outcomes of surveys and literature on how immigrant nurses acculturate could inform health care administrators and employers to ensure that they implement effective acculturation programs to assist immigrant nurses in transitioning smoothly into mainstream society. Successful acculturation could lead to improved perceptions of job satisfaction and quality of life that have significant implications on the delivery of quality and safe patient care.

SUMMARY This chapter describes and analyzes Berry’s theory on acculturation and how this idea has guided significant research studies that have delivered a better understanding of how individuals and groups adjust to a different culture. Although meaningful progress has been made in understanding this complex phenomenon, there are still areas that require further advancement and clarification, such as the development of a multidimensional instrument that could best measure the dynamic nature of the acculturative process. Another area is the need to cultivate a clear comprehension of the relationship between acculturation and health outcomes. Berry’s theory gives nurse researchers a theoretical framework with which to explore this concept and could be conducive in promoting a nurse-focused theory on acculturation.

REFERENCES Al-Omari, H., & Pallikkathayil, L. (2008). Psychological acculturation: A concept analysis with implications for nursing practice. Journal of Transcultural Nursing, 19(2), 126–133. Al-Omari, H., & Scheibmeir, M. (2009). Arab Americans’ acculturation and tobacco smoking. Journal of Transcultural Nursing, 20(2), 227–233.



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Alegria, M., Canino, G., Shrout, P. E., Woo, M., Duan, N., Vila, D., . . . Meng, X. L. (2008). Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups. American Journal of Psychiatry, 165, 359–369. Allen, M. L., Elliott, M. N., Fugligni, A. J., Morales, L. S., Hambarsoomian, K., & Schuster, M. A. (2008). The relationship between Spanish language and substance use behavior among Latino youth: A social network approach. Journal of Adolescent Health, 43, 372–379. Andrews, M., & Boyle, J. (2011). Transcultural concepts in nursing care (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Baker, D. (2011). Conceptual parameters of acculturation within the Asian and Pacific Islander American populations: Applications for nursing practice and research. Nursing Forum, 46(2), 83–93. Berry, J. W. (1980). Acculturation as varieties of adaptation. In A. M. Padila (Ed.), Acculturation: Theory, models, and some new findings (pp. 9–25). Boulder, CO: Westview Press. Berry, J. W. (1997). Immigration, acculturation, and adaptation. Applied Psychology, 46(1), 5–34. Berry, J. W. (2003). Conceptual approaches to acculturation. In K. M. Chun, A. Balls, P. B. Organi­ sta, & G. Marin (Eds.), Acculturation: Advances in theory, measurement, and applied research (pp. 17–37). Washington, DC: American Psychological Association. Brush, B. L., & Berger, A. M. (2002). Sending for nurses: Foreign nurse migration, 1965–2002. Nursing and Health Policy Review, 1(2), 103–115. Buscemi, C. P., Williams, C., Tappen, R. M., & Blais, K. (2012). Acculturation and health status among Hispanic American elders. Journal of Transcultural Nursing, 23(3), 229–236. Cabassa, L. J. (2003). Measuring acculturation: Where we are and where we need to go. ­Hispanic Journal of Behavioral Sciences, 25(2), 127–146. Choi, S., Rankin, S., Stewart, A., & Oka, R. (2008). Effects of acculturation on smoking behavior in Asian Americans: A meta-analysis. Journal of Cardiovascular Nursing, 23(1), 67–73. Daniel, P., Chamberlain, A., & Gordon, F. (2001). Expectations and experiences of newly recruited Filipino nurses. British Journal of Nursing, 10(4), 256–265. DiCicco-Bloom, B. (2004). The racial and gendered experiences of immigrant nurses from Kerala, India. Journal of Transcultural Nursing, 15(1), 26–33. Ea, E. E. (2007, November 30). Facilitating acculturation of foreign-educated nurses. OJIN: Online Journal of Issues in Nursing, 13(1). doi:10.3912/OJIN.Vol13No01PPT03 Ea, E. E., Quinn Griffin, M., L’Eplattenier, N., & Fitzpatrick, J. J. (2008). Job satisfaction and acculturation among Filipino registered nurses. Journal of Nursing Scholarship, 40 (1), 46–51. Ea, E. E., Itzhaki, M., Ehrenfeld, M., & Fitzpatrick, J. (2010). Acculturation among immigrant nurses in Israel and the United States. International Nursing Review, 57(4), 443–448. Fawcett, J. (2005). Criteria for evaluation of theory. Nursing Science Quarterly, 18(2), 131–135. Kim, J., Ashing-Giwa, K., Singer, M., & Tejero, J. (2006). Breast cancer among Asian Americans: Is acculturation related to health-related quality of life? Oncology Nursing Forum, 33(6), e90–e99. Lasseter, J. H., & Callister, L. C. (2009). The impact of migration on health of voluntary migrants in Western societies: A review of the literature. Journal of Transcultural Nursing, 20(1), 93–104. Lee, J. A. (2012). The relationship between acculturation and general health of Arab Americans. Journal of Transcultural Nursing, 23(2), 159–165. Leininger, M., & McFarland, M. (2002). Transcultural nursing: Concepts, theories, research and practices (3rd ed.). New York, NY: McGraw Hill. Magnusdottir, H. (2005). Overcoming strangeness and communication barriers: A phenomenological study of becoming a foreign nurse. International Nursing Review, 52, 263–269.

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Part II  Theories Applied to Research Redfield, R., Linton, R., & Herskovits, M. J. (1936). Memorandum for the study of acculturation. American Anthropologist, 38, 139–142. Social Science Research Council. (1954). Acculturation: An exploratory formulation. American Anthropologist, 56, 973–1002. Spector, R. (2004). Cultural diversity in health and illness (6th ed.). Upper Saddle River, NJ: ­Pearson Education. Steffen, P. R., Smith, T. B., Larson, M., & Butler, L. (2006). Acculturation to Western society as a risk factor for high blood pressure: A meta-analytic review. Psychosomatic Medicine, 68, 386–397. Withers, J., & Snowball, J. (2003). Adapting to a new culture: A study of the expectations and experiences of Filipino nurses in the Oxford Radcliffe hospitals NHS trust. NT Research, 8 (4), 278–290. Xu, Y. (2007). Strangers in strange lands: A metasynthesis of lived experience of immigrant Asian nurses in Western countries. Advances in Nursing Science, 30(3), 246–265. Yi, M., & Jezewski, M. A. (2000). Korean nurses’ adjustment to hospitals in the United States of America. Journal of Advanced Nursing, 32(3), 721–729. Zemore, S. E. (2007). Acculturation and alcohol among Latino adults in the United States: A comprehensive review. Alcoholism: Clinical and Experimental Research, 31(12), 1968–1990.

part iii

Theories Applied to Future Research and Practice

chapter 15

Story Theory Patricia Prufeta

Stories are a basic dimension of human interaction; they give one a deep and rich resource for understanding the human experience. In addition, stories are powerful in that they have the potential to heal. Stories connect people to people, events to other events, and times to other times (Taylor, 1996). During the process of taking care of patients, nurses hear patient stories. Story Theory, a middle range nursing theory developed by Smith and Liehr in 1999, is a theory that has wide application for nurses in their clinical practice and research. This chapter presents Story Theory in terms of its historical development, its core concepts, and the relationship among these core concepts. A literature review explores the theory’s relationship to other disciplines and to nursing metaparadigm concepts. An analysis of the theory describes, and three case studies present, how Story Theory has been used to mentor nurse managers in a large academic medical center. The chapter concludes with recommendations for further research and applications in nursing practice.

BASIC DESCRIPTION OF THE THEORY The developers of Story Theory, Liehr and Smith, believed that providing a storycentered framework between a nurse and a patient could guide nursing research and practice. The following text provides a description of the theory’s historical development, core concepts, and the relationship between the core concepts. Smith and Liehr have shared their views, beliefs, and values about nursing practice and research for many years. Smith’s initial research in 1975 was related to rest, while Liehr’s work in 1992 focused on determining if there was an effect on blood pressure when one was listening to a patient who was talking about a typical day (i.e., the patient’s story). A fortuitous meeting at a nursing conference led Smith and Liehr to discuss the importance of storytelling for improving health and promoting personal development. Both believed in the power of sharing stories and recognized the importance of building theory at the intersection of practice and research. Liehr and Smith’s work with pregnant teens and patients in cardiac rehab was the impetus for the first name of this theory, “Attentively Embracing Story,” after they

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observed each of these groups move on to a meaningful life once they participated in Story Theory care. The original name was changed to “Story Theory” between 2003 and 2006 for a number of reasons. First, feedback from students and colleagues was that the original name was difficult to remember. Second, people who tell their story do not always embrace the story. Third, the original name did not reflect the theory’s original intent of theory applicability to any situation where a nurse engages another person to discuss what matters about his or her health challenge (Smith & Liehr, 2008).

CORE CONCEPTS The tenets of Story Theory focus on the nurse meeting with a patient who is faced with a developing health issue. The nurse’s goal, in this situation, is to help the patient resolve the health challenge by having him or her tell stories. There are three main interrelated concepts in Story Theory (Smith & Liehr, 2008): (1) intentional dialogue, (2) connecting with self-in-relation, and (3) creating ease. Intentional dialogue is the “purposeful engagement with another to summon the story of a complicating health challenge” (Smith & Liehr, 2008). Conversation is directed toward a nurse engaging another person to talk about his or her life experiences (e.g., what makes him or her happy, past relationships, frustrations, and painful situations) to begin the process of transforming oneself. Connecting with self-in-relation is the “active process of recognizing self as related with others in a story plot” (Smith & Liehr, 2008). Creating ease is an “energizing release experienced as the story comes together in movement toward resolving” (Smith & Liehr, 2008). The first interrelated concept, intentional dialogue, is the main activity between the nurse and person that brings the story to life. The nurse focuses on the person, paying close attention to the unfolding story; both the nurse and person come to realize who they are. There are two components to intentional dialogue: intentional presence and querying emergence. Intentional presence, which is nonjudgmental, is essential as the nurse seeks clarification, identifies patterns, and/or helps the storyteller see potential meaning. Querying emergence requires the nurse to understand the story from the other’s perspective (Smith & Liehr, 2008). The second interrelated concept is connecting with self-in-relation, which has two components: personal history and reflective awareness. Personal history is the story told when an individual reflects on where he or she has been, where he or she is now, and where he or she will be. The nurse’s role is to encourage the person to tell the story of his or her unique life experiences, to make sense of the story, and to find meaning in the story. Reflective awareness involves being aware of one’s own feelings and thoughts. One is required to self-reflect and observe how the body is feeling at that moment and not let that feeling define who he or she is. As the nurse guides this part of storytelling, ease and trust are established (Smith & Liehr, 2008). The third interrelated concept involves creating ease. This concept occurs as the story comes together and moves toward resolution. As the story unfolds, the nurse enables the person to connect events through awareness, understanding, and acceptance. Patterns emerge as the individual reflects on his or her life’s experiences. This relationship among intentional dialogue, connecting with self-in-relation, and creating ease is considered to be a dynamic interrelationship (Figure 15.1). As the nurse gathers data about the patient’s complicating health challenge, he or she asks the patient to reflect, focusing on issues that matter most to him or her. This process is



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Figure 15.1  Relationship among intentional dialogue, connecting with self-in-relation, and creating ease for patients confronting a health challenge.

Connecting With Self-in-Reaction

Nurse

Patient

Source: Smith and Liehr (2008).

known as developing the story plot. Movement toward resolving the problem occurs when the storyteller becomes engaged in the health challenge and begins to see the challenge as manageable. Story Theory is not applicable to all situations. First, Story Theory is geared toward people with health challenges. Since Story Theory requires repeated sessions, this theory would not be used for healthy persons, as these people would not require recurring visits with a nurse. Second, one must be able to trust, as trust is necessary for a person’s story to unfold. Establishing trust usually requires more than one visit. Third, the nurse must be able to identify salient points in the person’s story in order to guide the person toward increased insight. Fourth, the person must be ready to start the journey of unfolding the story and embrace the story as it unfolds. Finally, not all individuals are in a place of readiness; thus, the insight leading to ease cannot be accomplished.

RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS THEORY Multidisciplinary research exists about the power of stories and narratives. A narrative is defined as the retelling of something that has happened. Rita Charon, a physician, described the importance of the patient’s narrative in clinical practice. She spoke of the significance of the narrative to “recognize, absorb, interpret, and be moved by the story of illness” (Charon, 2006). Charon’s research proposed that narratives could improve a patient’s compliance by decreasing misunderstandings between the physician and the patient.

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McAdams, a professor of human development from Northwestern University, described stories as narratives that teach. “Stories instruct. We learn how to act and live through stories. We learn about different people, settings, and ideas.” He proposed that stories “move us to psychological fulfillment and maturity” (McAdams, 1993).

RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS Fawcett defined a metaparadigm as the global concept that identifies the phenomenon of central interest to a discipline, the global propositions that describe the concepts, and the global propositions that state the relations between or among the concepts (Fawcett, 2005). For the discipline of nursing, the central concepts are human being or person, environment, health, and nursing. The way in which Story Theory relates to these concepts include the following: ●●

●● ●●

●●

Human being or person: Story Theory occurs in a nurse–person relationship. The nurse listens attentively to a story about a health situation that matters most to the person. Environment: Story Theory contributes to creating a safe and trusting environment. Health: A complicating health challenge is “any circumstance where a life change or pattern disruption generates uneasiness in everyday living.” This life change can be a new onset of an illness, a divorce, or empty-nest syndrome that causes discomfort (Smith & Liehr, 2008). Nurses: The nurse gathers the story by focusing on the patient while listening attentively, asking questions, identifying patterns, and finding potential meaning.

THEORY ANALYSIS To determine if nurse managers who are mentored using Story Theory have more effective communication skills, this research selected Story Theory because its core elements are centered on communication. An analysis of the ways in which Story Theory provided the framework follows. Table 15.1 provides a summary of this analysis. Story Theory is a good fit for mentoring nurse managers because it focuses on the power of stories. The process of mentoring involves discussions with one’s mentee, who tells stories of his or her experiences. In addition, the core concepts of Story Theory (intentional dialogue, connecting with self-in-relation, and creating ease) are essential elements in building a trusting relationship that needs to occur when mentoring. Self-awareness regarding “what is most important” is necessary when helping a manager improve his or her behavior. The core concepts mentioned above make the theory very easily adapted in discussions with a manager. The assumptions of Story Theory are congruent with the research question. First, the director and nurse manager connect the past and future to the present. Second, both the director’s and nurse manager’s awareness expands during the mentoring sessions. Finally, over the course of the mentoring process, both the director and the nurse manager make connections with the interrelatedness of themselves, which leads to change.



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Table 15.1 Evaluative Criteria and Use of Story Theory in Mentoring Nurse Managers Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

Story Theory involves the patient (in this case, the nurse manager) telling his or her story to the nurse during the health promoting ­process. This theory has been adapted to explore how it can be ­utilized by a director of nursing in an acute care area when mentoring nurse managers.

2.

Is it readily operationalized?

Yes, the theory’s three core concepts (intentional dialogue, connecting with self-in-relation, and creating ease) are essential to building a trusting relationship with a manager.

3.

How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it relates?

Story Theory used, along with exercise and nutrition counseling, for patients with Stage 1 hypertension resulted in these patients having statistically significantly lower systolic blood pressures (Liehr, 2006). Hain (2008) used the story path approach with 63 older adults undergoing hemodialysis to study the relationship between word use in stories of lifestyle changes and cognitive function. Jolly, Weiss, and Liehr (2007) utilized Story Theory to determine how vulnerable adolescents in an urban practice setting came to know the meaning of “voice.”

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

Story Theory promotes health in a nurse–person relationship. This theory addresses the research hypotheses that directors who use Story Theory to mentor nurse managers will produce managers with better communication and leadership skills.

5.

Does the theory flow from the research question?

The research question has potential to explore the effectiveness of Story Theory when mentoring nurse managers. This theory guided the development of the research questions and hypothesis.

6.

Does the theory address the primary and secondary research questions?

The theory addresses the primary question, “Do nurse managers who are mentored using Story Theory have better communication skills?” The secondary question is, “Do nurse managers who are mentored using Story Theory have better patient outcomes and staff satisfaction?”

7.

Are the assumptions congruent with the assumptions that are made for research?

The assumptions are congruent with the assumptions that are made for the research in that (a) the patient and nurse manager connect past and future to the present, (b) there is a nurse–patient relationship in Story Theory and a director–manager relationship in the research study, (c) the patient/nurse and director/nurse manager awareness expands, and (d) the patient and the manager make connections with the interrelatedness of themselves, which leads to change.

8.

Is the theory oriented to outcomes that are critical to patients?

The theory is oriented to outcomes that are critical to patients as it asks the question “what matters most” to the patient facing a health challenge. Nurse managers ask “what matters most” when facing challenges during one-on-one sessions.

9.

Are tools available to test relationships of the theory or do they need to be developed?

Tools need to be developed to test relationships of the effectiveness of utilizing Story Theory when mentoring nurse managers.

Source: Fawcett (1999, 2005).

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Story Theory asks “what matters most,” which is an essential component of the mentoring process. To date, no tools have been developed to test relationships of the effectiveness of utilizing Story Theory when mentoring nurse managers.

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING Story Theory has been used effectively in combination with lifestyle interventions to lower blood pressure in patients with Stage 1 hypertension. In addition, Story Theory has been used in research regarding drinking and driving (Smith & Liehr, 2005) and setting aside life burdens (Liehr & Smith, 2000). Summers (2002) used the theory as a foundation for effective health care encounters. In 2008, Hain described “what matters most” in her research study with hemodialysis patients. Heiney (1995) developed a conceptual framework in which stories were used to help patients find meaning in their cancer experience. When using this theory, Heiney advised nurses to listen to patients’ stories with an open mind. Heiney provided examples of how stories can be used as specific treatment strategies to help patients and families gain new perspectives regarding their health situations. According to Heiney, health care providers could extend their helping abilities if they took time to listen to the patient’s story or if they told their own story as a therapeutic intervention. Chelf, Deschler, Hillman, and Durazo-Arvizu (2000) used this framework to develop a community-based storytelling workshop as a way to help cancer patients and families cope with diagnosis and treatment. Their findings showed that 97% of participants felt that storytelling was beneficial in helping them cope with cancer. Likewise, Simmons (2001) identified that stories could be a path for creating faith in one’s self, one’s goals, and one’s hopes. She further asserted that telling meaningful stories could inspire listeners, who would ultimately draw their own conclusions, thus alluding to the tremendous power stories have to connect us.

USE OF THE THEORY IN THIS RESEARCH Nurse managers are the lynchpin to running successful clinical units in hospitals (Akerjoret & Severinsson, 2008). Senior leadership at a large metropolitan hospital in New York City refers to nurse managers as the “CEOs of units,” saying that nurse managers are key to positive staff, patient, and organizational outcomes. Having high-performing nurse managers leading clinical care units is imperative to a highly functioning organization. Despite this, very little is invested in training and, more important, in mentoring future nurse managers. This section examines how Story Theory can be used to mentor nurse managers. Case studies demonstrate how Story Theory can be implemented to improve performance of a novice nurse manager who is struggling in her role as well as how Story Theory drives experienced nurse managers to reach their potential and excel as nurse leaders.

Case Study 1 The first case study involves a novice nurse manager who was struggling to lead her clinical unit. This nurse manager, who will be referred to as CW, had several performance issues, including complaints about her communication style, from physicians



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and staff, as well as poor employee satisfaction scores. These issues warranted a Work Improvement Plan with specific, measurable outcomes. The first step involved in developing the Work Improvement Plan was to collect data. For the director, it was important to meet with all the key stakeholders: the manager from human resources (HR), physicians, unit staff, and CW. This factfinding process required both careful listening and being “truly present.” Physicians stated that CW was not visible on the unit and was not an active participant in interdisciplinary rounds. The HR manager, who was seen as objective and not part of the staff, met with staff on both the day and night shifts. Differences were noted between the shifts: The day shift found CW to be an effective communicator, while the night shift complained that she was rarely seen on the unit and that she had poor communication skills. During the meeting with the HR manager, CW agreed with the above findings and stated that she realized that her communication style was an issue. The annual employee opinion survey supported the assessment findings. Overall job satisfaction on CW’s clinical unit was 70% as compared to the hospital’s score of 83%. CW’s management score was 46% compared to the hospital’s overall management score of 68%. A decision was made to place CW on a Work Improvement Plan, which included goals and measurable outcomes. The Work Improvement Plan (Table 15.2) was shared with CW. She was informed that continued employment was based on successfully meeting the objectives set forth in the plan within the specified timeframes. Elements of the plan, including how Story Theory is integrated in this plan, are described below. Table 15.2  Work Improvement Plan Area of concern

Goal

Action plan (for CW)

How measured

Communication with night staff

Improved communication with night staff within 90 days

*Meet with the night charge RN every morning to get report. *Check with staff each morning regarding any concerns. *Work a week of nights every quarter. *Schedule one-on-one sessions with the night staff on a biannual basis. *Recognize and reward staff for positive outcomes and behaviors (e.g., positive feedback statements, certificates, etc.)

*As of February 2013, the director will make weekly rounds at night to talk to staff and get feedback about issues and concerns and to determine if communication has improved. *In March 2013, Human Resources will meet with the night staff to determine if there has been improvement in communication. *In April 2013, a Pulse ­Survey will be taken regarding improvement in communication.

Communication with physicians

Improved communication/relationships with physicians within 90 days

*On a daily basis, attend and actively participate in multidisciplinary rounds. *Meet weekly with the hospitalist on the unit to discuss concerns and elicit feedback.

*Director will meet with physicians on a bimonthly basis to seek feedback.

Note: Over the next 90 days we will meet weekly to discuss your progress. I will work closely with you to provide support and feedback. Continued employment will be contingent on your ability to meet and to consistently sustain all performance objectives.

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The interim director scheduled weekly one-on-one meetings with CW and wove all three of the components of Story Theory (intentional dialogue, connecting with self-inrelation, and creating ease) into these sessions. In the initial meeting, the interim director reviewed the assessment findings (intentional dialogue, developing the story plot). Intentional dialogue meant having uninterrupted time (e.g., having the door closed, taking no phone calls, and not checking e-mail on a cell phone). Listening was imperative, as the group sought clarification of the issues. The interim director asked questions of CW regarding the assessment issues, including her suggestions for improvement strategies. In this meeting, CW identified that she was often successful in handling patient concerns and complaints. This information indicated that CW had a skill set that could be useful when communicating with staff. At one point in the discussion, the director asked CW, “What do you do when you communicate with patients that you could use when talking to staff?” CW replied, “I listen, I really listen. I sit with the patient for a few minutes and really connect with them, eye to eye.” She had her “aha moment” (connecting with self-inrelation). CW stated that she would implement this same strategy with her staff. She committed to spend time with the night shift every morning, listen to concerns (creating ease, movement toward resolving), and be truly present with them when they communicated. Two goals were identified for the Work Improvement Plan: (1) to improve communication with staff and (2) to improve communication with physicians. The group established a timeframe of 90 days in which these goals needed to be met and identified specific strategies to improve communication with both the night staff and physicians. All strategies identified in the Work Improvement Plan were designed to create ease, movement toward resolving. The second and third case studies illustrate how a director used the concepts of Story Theory to develop two high-performing nurse managers, MM and DD. Both managers led their units efficiently and effectively (e.g., had positive patient outcomes and high employee satisfaction scores). Also, both managers had been identified as key promotional talent in the organizational talent review. When questioned as to what was most helpful to their development as nurse leaders, these two high-performing nurse managers identified a number of themes. According to MM, the most important factor was that the director was solely focused on him during one-on-one sessions; the director was  “really present” and possessed excellent “listening” skills (intentional dialogue). The other manager, DD, reported that the director listened with “full attention,” giving the impression of truly caring when listening to a story. Mentoring sessions “felt safe” and nonjudgmental (creating ease). Both nurse managers also stated that the director let them figure out their own solution to a problem or a situation (connecting with self-in-relation). As has been identified in the preceding paragraph, the three interrelated concepts of Story Theory emerge: (1) intentional dialogue, (2) connecting with self-in-relation, and (3) creating ease. These themes were also apparent in the first scenario of the novice nurse manager. The importance of establishing trust, determining what matters most, clarifying issues and identifying patterns, noting progress or lack of progress, and interpreting the possible meaning to a story are all critical to mentoring any nurse manager.

Case Study 2 The second case study involves MM, the nurse manager on a surgical unit. MM was an outspoken person who told things “like they were.” Feedback from people present at meetings when MM made statements was that his comments were often



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“politically offensive”; it was not what he said but how he said it. In addition, when MM came to leadership meetings with the vice president of nursing, he always sat in the back row with the same group of people. MM used his cell phone continuously and often had side conversations with the people with whom he was sitting, which gave the impression he was not interested in the meeting. Finally, the vice president of nursing spoke to the director about MM’s disruptive behaviors. In addition to the previous issues, MM also had a habit of interrupting people; he failed to listen attentively and responded to people before thinking. Feedback from staff was that he always interrupted a person when he or she was speaking at a meeting. Discussions at one-on-one mentoring meetings with MM required the director to both listen carefully and to be “truly present.” The director presented her observations regarding the previous situations. Listening, as in the prior case study, was important in order to obtain MM’s explanations of these behaviors (intentional dialogue, developing the story plot). MM was surprised to hear feedback about his comments at meetings being “politically offensive.” He stated that his intention was to “just tell it like it is.” Feedback from the vice president of nursing and staff on the unit about his behaviors was critical to MM realizing how he did not pay attention at meetings and how often he interrupted staff on his unit when talking with them. MM explained that he never could catch up on his e-mail, so he used time at the leadership meeting to accomplish this. He also explained that his passion and enthusiasm for “doing the right thing” for patients often led him to interrupt staff and make comments without any filter (connecting with self-in-relation, developing the story plot). One-on-one mentoring sessions with MM focused on communication, as this was a consistent theme in all of his performance issues. The director asked MM to identify strategies that would improve his performance issues (creating ease). To improve political savvy, MM decided that it would be best to discuss his insights about how conversations had gone with the director. During mentoring meetings, MM practiced communicating his message in a more positive way while articulating concerns in a meaningful way (creating ease, connecting with self-in-relation). MM’s solution to using his cell phone and having side conversations with others at leadership meetings was to sit in the front of the room and put his phone in his pocket. Thus, he would be giving his full attention to what was being said at the meeting. To avoid interrupting staff when they were talking, MM resolved to let staff complete what they were saying before he commented. With time, maturity, self-­ awareness, and Story Theory mentoring, MM learned to slow down and think before acting and speaking (moving toward resolution).

Case Study 3 The third case study involves DD, the nurse manager on an oncology unit. DD, who had more than 30 years of experience, had always run an efficient oncology unit and had some of the strongest clinical nurses in the hospital. Nurses on the unit were frequently recognized for clinical excellence during Nurses’ Week. Oncology nurses took the lead when it came to utilizing complementary therapies for patients. Despite this, staff nurses on this unit stated that this nurse manager was “tough” and sometimes “unapproachable.” Feedback from other disciplines and departments was that DD was inflexible and that she often was heard saying “too much is going on; too many things are being changed all at once.” One example of DD’s inflexibility was

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her refusal to return to school to pursue her master’s degree. The day of reckoning came when the hospital mandated that all nurse managers needed to have a master’s degree. In order to facilitate this, the hospital had partnered with a prestigious graduate nursing school to develop a customized program for future nurse leaders. This mandate was a turning point in DD’s career. During one-on-one using storytelling mentoring sessions (intentional dialogue, creating ease), DD made the decision, somewhat reluctantly, to return to school (connecting with self-in-relation). Over time, she became more open to new ideas and began to embrace a new way of “seeing” things (connecting with self-in-relation). Feedback from staff and other department staff became increasingly positive.

Figure 15.2  Relationship among intentional dialogue, connecting with self-in-relation, and creating ease for nurse managers with a performance issue. Connecting With Self-in-Relation Challenge CW identifies areas of improvement. Director asks questions to identify patterns. Intentional Dialogue Developing Story-Plot

Director

Weekly one-to-one sessions with CW attentive listening and truly present

Nurse Manager

Creating Ease Movement Toward Resolving CW identifies strategies for improvement. Trust forms with repeated sessions.

High-performing nurse manager

High employee and patient satisfaction

Adapted from Smith and Liehr (2008).

Positive patient outcome



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RECOMMENDATIONS FOR FURTHER RESEARCH AND PRACTICE Research about the application of Story Theory in mentoring nurse managers does not appear in the literature. Because of the lack of evidence in the literature about Story Theory and because Story Theory has so many connections to the nursing experience, the following research questions are posed: 1. Do nurse managers who are mentored using Story Theory have more effective communication skills than those who do not have Story Theory incorporated in the mentoring process? 2. Do nurse managers who receive mentoring using Story Theory have better patient and staff outcomes than those who are not mentored using Story Theory? Figure 15.2 illustrates the linkages between the concept of Story Theory and the research questions described in the previous list. The first part of the diagram illustrates interrelated and dynamic concepts of intentional dialogue, connecting with self-in-relation, and creating ease. When using intentional dialogue, the director must have uninterrupted time with the nurse manager to guide him or her through the story (developing the story plot). With repeated sessions between the director and nurse manager, patterns will emerge, and the director will help the nurse manager see possible solutions to challenges as they arise (connecting with self-in-relation). As the nurse manager implements new strategies (creating ease), he or she will begin to see improvements in patient and staff outcomes. The bottom portion of the diagram relates to the second research question. This section illustrates how high-performing managers who have been mentored using Story Theory have high employee satisfaction scores and positive patient outcomes. In today’s health environment, high-performing nurse managers are key to positive patient outcomes, satisfied staff and patients, and financial reimbursement for hospitals.

SUMMARY The purpose of this chapter was to examine Story Theory and its impact on mentoring nurse managers. The theory was discussed regarding its historical development, core concepts, and the relationship among the core concepts. A review of the research explored the theory’s relationship in nursing and other disciplines, and a table illustrated an analysis of the theory. Three case studies were presented on how Story Theory has been used to mentor nurse managers. Key components of Story Theory were critical during one-on-one mentoring sessions. In each case study, a nurse manager faced challenges and developed selfawareness that was necessary to make changes in his or her actions and behaviors. The novice nurse manager, CW, is optimistic about her future with ongoing, consistent, and formalized mentoring using Story Theory. The two experienced nurse managers, MM and DD, have shown considerable improvement in their performance. Both of these managers were promoted to director within the past year. This chapter has illustrated how mentoring using Story Theory can be effective in improving communication and leadership skills of nurse managers. More research in

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this area is necessary. Mentoring nurse managers is not only our responsibility but a privilege to cultivate future nurse leaders. The evidence is clear: Strong nurse managers result in positive staff and patient satisfaction and outcomes.

REFERENCES Akerjordet, K., & Severinsson, E. (2008). Emotionally intelligent nurse leadership: A literature review study. Journal of Nursing Management, 16(5), 565–577. Charon, R. (2006). Narrative medicine: Honoring the stories of illness. New York, NY: Oxford University Press. Chelf, J. H., Deschler, A., Hillman, S., & Durazo-Arvizu, R. (2000). Storytelling: A strategy for living and coping with cancer. Cancer Nursing, 23(1), 1–5. Fawcett, J. (1999). The relationship of theory and research (3rd ed.). Philadelphia, PA: F.A. Davis. Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (2nd ed.). Philadelphia, PA: F.A. Davis. Hain, E. (2008). Cognitive function and adherence of older adults undergoing hemodialysis. Nephrology Nursing Journal, 35(1), 23–30. Heiney, S. P. (1995). The healing power of story. Oncology Nursing Forum, 22(6), 899–904. Jolly, K., Weiss, J. A., & Liehr, P. (2007). Understanding adolescent voice as a guide for nursing practice and research. Issues in Comprehensive Pediatric Practice, 30(3), 3–13. Liehr, P., Meininger, J. C., Vogler, R., Chan, W., Frazier, L., Smalling, S., et al. (2006). Adding story-centered care to standard lifestyle intervention for people with Stage 1 hypertension. Applied Nursing Research, 19, 16–21. Liehr, P., & Smith, M. J. (2000). Using story theory to guide nursing practice. International Journal of Human Caring, 4, 13–18. McAdams, D. P. (1993). The stories we live by: Personal myths and the making of the self. New York, NY: Morrow. Smith, M. J., & Liehr, P. (1999). Attentively embracing story: A middle range theory with practice and research implications. Scholarly Inquiry for Nursing Practice: An International Journal, 13, 187–204. Smith, M. J., & Liehr, P. (2005). Story Theory: Advancing nursing practice scholarship. Holistic Nursing Practice, 19(6), 272–276. Smith, M. J., & Liehr, P. R. (Eds.). (2008). Middle range theory for nursing (2nd ed.). New York, NY: Springer Publishing Company. Simmons, A. (2001). The story factor. Cambridge, MA: Basic Books. Summers, L. (2002). Mutual timing: An essential component of provider/patient communication. Journal of the Academy of Nurse Practitioners, 14, 19–25. Taylor, D. (1996). The healing power of stories. New York, NY: Doubleday.

chapter 16

Self-Transcendence Theory Jean Marie DiNapoli, Mary Joy Garcia-Dia, Leila Garcia-Ona, Deirdre O’Flaherty, and Jennifer Siller

The Theory of Self-Transcendence is a middle range theory of nursing developed by Pamela Reed. According to Reed (2012), the purpose of the Theory of Self-­ Transcendence is to “provide a framework for inquiry and practice regarding promotion of well-being in the midst of difficult life situations, particularly where individuals and families face loss or life-limiting illness” (p. 1). Reed (2012) explained how the theory was rooted in the quest to understand how life and developmental experiences by older adults affect mental health and well-being. It was originally constructed to better comprehend the role of self-transcendence at the end of life when one is faced with his or her own mortality. However, with new findings through extensive research, the boundaries of the theory have expanded across the life span to include children and young adults. In this chapter, an analysis of the scope and context of the Self-Transcendence Theory is provided, including its core concepts and the relationship among them. Also, a demonstration on how the theory is applied to practice using criteria identified by Fawcett (2005) is presented.

BASIC DESCRIPTION OF THE THEORY The idea for the Theory of Self-Transcendence was originally established from major inspirations in the history of science, the history of nursing, and Reed’s own professional history (Reed, 2012). The life-span movement of the 1970s helped declare that developmental change in a person’s life was influenced less by age and more by life-changing events that had occurred. Also, Martha Rogers’s (1970) writings about nature of change in human beings and her life-span principles of development helped shape the theory’s development. Finally, Reed’s own “practice experience in applying developmental theories in child and adolescent psychiatric-mental health care” (2012, p. 2) required knowledge of a patient’s developmental growth. Reed (2009) identifies the primary source of the theory’s development from a combination

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of life-span theories on adult social cognitive and transpersonal development. Martha Rogers’s conceptual system, the Science of Unitary Human Beings, provided the nursing component of human development that facilitated reformulating the knowledge about self-transcendence that was originally derived from non-­nursing theories. Initially, the theory focused on self-transcendence as it materialized in later adulthood. However, through research the theory has expanded its boundaries to include self-transcendence as a facilitator for well-being across the life span, especially during times of life-changing events that elevated a person’s sense of vulnerability or mortality.

CORE CONCEPTS The Theory of Self-Transcendence depends upon two major assumptions. The first assumption arose from Rogers’s Science of Unitary Human Beings: Human beings are integral with their environments. “Human beings are ‘pandimensional’ (Rogers, 1980, 1994), coextensive with their environment, and capable of an awareness that extends beyond physical and temporal dimensions” (Reed, 1997a). Self-transcendence is a concept that unites individuals with themselves, their surroundings, their spirituality, and others. The second assumption is that self-transcendence is a vital part of an individual’s development. This development is an innate form of a person’s developmental processes, such as laughing when happy and crying when sad. These experiences help enable individuals to realize their potential for well-being. There are three core concepts in the Theory of Self-Transcendence: self-­ transcendence, well-being, and vulnerability. Self-transcendence, the first major concept of the theory, refers to “the capacity to expand self-boundaries in a variety of ways” (Reed, 2012, p. 4). As described by Reed, self-boundaries can be expanded in many different ways, such as: Intrapersonally (toward greater awareness of one’s philosophy, values, and dreams), interpersonally (to relate to others and one’s environment), temporally (to integrate one’s past and future in a way that has meaning for the present), and transpersonally (to connect with dimensions beyond the typically discernible world). (p. 4) Reed describes self-transcendence as a characteristic of developmental maturity, which results from life experiences, a greater awareness of one’s environment, and one’s own awareness of his or her inner self. Reed theorized people facing negative life-altering events may experience a greater awareness of their selves and environment. “Self-transcendence is expressed through various behaviors and perspectives such as sharing wisdom with others, integrating the physical changes of aging, accepting death as part of life, having an interest in helping others and learning about the world, letting go of losses, and finding spiritual meaning in life” (2012, p. 5). Well-being, the second major concept of Reed’s theory, is defined by Reed as “a sense of feeling whole and healthy, in accord with one’s own criteria for wholeness and health” (p. 5). Reed describes well-being as having multiple definitions and



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diverse indicators. She further explains that the definition of well-being may vary depending upon the individual or patient population. Indicators of well-being are described by Reed as “diverse as human perceptions of health and wellness” (p. 6). Examples of indicators of well-being described by Reed include happiness, satisfaction with life, positive self-concept, hopefulness, and sense of meaning in life. As part of an individual’s development, self-­transcendence positively impacts healthpromoting experiences in individuals. “Well-being is a correlate and an outcome of self-transcendence” (2012, p. 6). Vulnerability is the third major concept of the theory. As described by Reed, vulnerability occurs through experience of difficult life events such as illness, trauma, or loss of a loved one. Vulnerability is also described as an awareness of one’s own mortality. When a person is vulnerable and overcomes difficult life events, it is theorized that the person self-transcends and achieves a state of well-being. In order for a person to self-transcend and reach a state of well-being, feelings of vulnerability must be present. As explained by Reed (2010), the concepts are broadly defined to allow for use in various situations where a person faces health challenges. According to Reed (2012), there are four basic relationships present among the concepts of the theory. The first relationship exists between vulnerability and selftranscendence. Reed describes that this relationship “may be nonlinear and that very low and very high levels of vulnerability may not relate to increased levels of selftranscendence, or at least not without the influence of other factors in that relationship” (p. 7). Reed describes the second relationship that exists between well-being and self-transcendence as a direct and positive one. An example of this is when “selftranscendence relates positively to a sense of well-being and morale but relates negatively to a level of depression, as a ‘negative’ indicator of well-being” (2012, p. 7). The third relationship is the effect that self-transcendence has on the relationship between vulnerability and well-being. “Self-transcendence may mediate the effects of vulnerability (experienced for example as illness distress; lack of optimism, hope or power; uncertainty; or death anxiety) on well-being” (Reed, 2012, p. 7). Finally, the relationship that exists among the three concepts relies on how personal factors (e.g., age, gender, past significant life events, and personal beliefs) may play a role in the healing process. These factors can improve or decrease the strengths of the key variables and their relationships.

Research from other disciplines RELATED TO THIS THEORY Abraham Maslow, the founder of humanistic psychology, developed the hierarchy of needs, where a person’s motives are explained in a five-level hierarchical pyramid with basic needs at the bottom and needs for self-actualization, such as identity, at the top (Ventner & Ventner, 2010). According to the authors, before Maslow died, he identified a sixth tier of need, which he believed very few people were capable of achieving in their lifetime—self-transcendence. Ventner and Ventner (2010) defined self-transcendence as a person’s ability to obtain a unitive consciousness through illuminations and insights gained from life-altering experiences. The person sees other human beings on a global scale and is more aware of the impact he or she has not just within his or her own boundaries but on the whole world. These transcended individuals, in an effort to reach the top of Maslow’s revised hierarchy, typically seek a

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benefit beyond the mere personal, identifying with something greater than the purely individual self and often engaging in selfless service to others. The massive migration of people all over the world and modern technological advances in communication make it possible to reach Maslow’s sixth level, self-transcendence. According to Delio (2003), Newberg researched on the relationship of brain activity to religious activities. It was found that both monks and nuns, after prolonged prayer or meditation, have reported intense religious experiences that include a consciousness of union. Since this level of consciousness is neither wholly subjective nor objective, they have been described as transcendent experiences. Newberg identified the experiential transcendent state during prayer or meditation as Absolute Unitary Being (AUB), a state of pure awareness, a clear and vivid consciousness of nothing (Delio, 2003). According to Newberg, d’Aquili, and Rause, “. . . for the Buddhist, the union consisted of a sense of timelessness and infinity, feeling part of everyone and everything in existence . . . For the nuns, it was an awareness of the closeness of God and a ‘mingling with Him’” (Newberg, d’Aquili, & Rause, 2001, p. 2). As further stated by Delio (2003), the implication of Newberg et al.’s research is the idea that humans may have physiological structures and mechanisms for spiritual experience or religious self-transcendence. Newberg and his colleagues describe the reality of the mystery of God as integrally bound to the human brain. Newberg et al.’s data suggest that we not only have the capacity for self-transcendence but also the underlying mechanisms of transcendence. According to Garcia-Romeu (2010), Reed’s Self-Transcendence Theory has demonstrated some congruence with gerotranscendence. Tornstam (1996, 1997) coined the term gerotranscendence after discovering a link between aging and selftranscendence. Tornstam defines gerotranscendence as a shift in metaperspective, from a midlife materialistic and rational vision to a more cosmic and transcendent one, accompanied by an increase in life satisfaction. Initial research findings using the Adult Self-­Transcendence Inventory (ASTI) found that self-transcendence as measured by the ASTI exhibits significant negative correlation to neuroticism, and is positively related to meditation practice (Levenson, Jennings, Aldwin, & Shiraishi, 2005). Furthermore, a 2007 dissertation by Zappala found positive correlations between self-transcendence, psychological and subjective well-being, quality of life, and mindfulness using the ASTI tool (Garcia-Romeu, 2010). Teachers are challenged to maintain discipline, be firm and forceful, and control the class, encouraging students to take the course and content seriously (Gordon, 2010). This institutional authority inhibits teachers from adopting a humorous attitude in coping with multiple challenges that, over time, can cause them to lose hope, potentially leading to burnout. Gordon (2010) suggested that “self-transcendence and the capacity to take themselves less seriously can help teachers maintain their composure and keep things in perspective in those moments that call for a more stern and businesslike approach” (p. 748). He states, “people enjoy laughing at themselves, are generally able to transcend their immediate, self-absorbed situation, even when that state is uncomfortable” (p. 743). For students to view teachers as approachable, trustworthy, and open-minded, teachers need to have the ability to transcend their self-perception as authority figures and to see themselves as others do. Gordon concluded that, “selftranscendence and the ability to laugh at ourselves are, generally speaking, healthy responses that can facilitate the development of several qualities we value in teaching. Responding with humor can also help teachers negotiate many of the daily challenges that characterize this critical, highly complex field we call education” (p. 749).



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relationship of the theory to nursing metaparadigm concepts According to Fawcett (2005), “the discipline of nursing is the study of the interrelationships among human beings, environment, health, and nursing” (p. 2). The Theory of Self-Transcendence embraces the dynamic relationship of person, environment, health, and nursing. Self-Transcendence Theory proposes that individuals who face vulnerability or mortality may develop an increased capacity for self-­transcendence and its positive influence on mental health and well-being. Reed (1996) described self-transcendence as a “developmental capacity that becomes evident in health experiences that confront the person with personal mortality and immortality through health experiences of aging, illness, and loss” (p. 3). It is a holistic perspective of both health and of healing and can be a powerful coping strategy. The foundation of the theory is based on Rogers’s Science of Unitary Human Beings, in which a person is viewed as an open living system and not as passive but intrinsically active and innovative (Reed, 2012). Self-transcendence is a connection with others. The consequences of this connection foster a feeling of well-being and healing. It provides a path to find meaning and purpose in life and the ability to cope with illness, pain, or suffering. Coward (2003) found that self-transcendence seems to help coping by allowing adults to find meaning and well-being even during difficult circumstances. According to Reed, late adulthood is characterized by certain resources and challenges. Self-transcendence has been identified as one particular resource of later life. The theory explains how aging and/or vulnerability can propel humans beyond self-boundaries to focus intrapersonally on life’s meaning; interpersonally on connections with others and the environment; temporally to integrate past, present, and future; and transpersonally to connect with dimensions beyond the physical reality. It is applicable to any person, regardless of age, whose life situation increases an awareness of personal mortality (Ellermann & Reed, 2001; Reed, 2003). The significance of self-transcendence centers on the holistic perspective of health and healing (Texeira, 2008, p. 25). Although health is influenced by physical, spiritual, social, and/or psychological realms, the individual’s definition of one’s well-being is dependent on what he or she considers as important (Runquist & Reed, 2007). According to Reed: Rogers . . . proposes that human change is innovative as well as irreversible and unpredictable. This capacity for innovation is reflected in ­individual’s ability to undergo positive changes and experience wellbeing even in difficult health experiences. . . . Acknowledging in inner potential for well-being, can be a source of hope in illness and end-of-life. (2010, p. 419) Reed theorizes that self-transcendence as a nursing process can be directly related with positive, health-promoting experiences. Over the span of two decades, self-transcendence has been found to apply across cultures from the Americas to Asia (Reed, 2009). According to Dodd, Miaskowski, and Paul (2001), the environmental domain includes physical, social, and cultural variables. Serious health events can impact an individual’s immediate or perceived environment. They may be challenged with new people, technology, or a diagnosis

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that forces them to make a life-changing decision or be faced with the reality of a new self-image. Reed (2012) defines self-transcendence as the extension of one’s conceptual limitations by self-reflection through introspective activities, and outwardly through concerns about others’ well-being, and temporally by incorporating one’s awareness of his or her past and future to augment the present. A focus of nursing as described by Reed (2012) is to facilitate well-being and understand the capacity for well-being when a person is facing difficult healthrelated experiences. To further understand the nurse’s role in facilitating selftranscendence in patients who have experienced a life changing event, Reed (1996) explains that the nurse “facilitates transcendence by helping the person translate explicate (observed) patterns in the person’s life into awareness of and fuller participation in the implicate (underlying) pattern that is unfolding, that is, to expand consciousness” (p. 3). Self-transcendence is a relevant nursing concept that can be achieved through the use of spiritual perspective, hope, and acceptance, all contributing to health-promoting experiences. As a primary nursing process, self-transcendence is used by patients or families, while the nurses’ role of intervention becomes a secondary process. According to Hunnibell, Reed, Quinn-Griffin, and Fitzpatrick (2008), nurses play a major role by assisting patients in the healing process through self-transcendence and identified major interventions. This includes connecting with nurses, forming support groups to share experiences, and increasing their own awareness, which facilitates healing for themselves first. These interventions promote a sense of self-worth and purpose by organizing a bereavement committee or staff support committee. Increasing awareness of the nurse’s unique caring role by writing journals and storytelling about positive individual contributions and personal “gifts,” each nurse contributes to improve patient care and instill a sense of belonging to a greater cause by exploring the dimensions and meanings of spirituality, as well as fostering new awareness to establish a sense of connection to oneself, others, and the environment. In a study done on the relationship of engagement and self-transcendence, it was found that nurses with higher levels of self-transcendence have more energy and dedication, and therefore are more absorbed in their work (Palmer, Quinn-Griffin, Reed, & Fitzpatrick, 2010). By providing opportunities for self-transcendence, nurses can be more engaged and better able to cope with the constantly changing health care environment.

Theory analysis Reed’s Theory of Self-Transcendence is a developmental process applicable to any person, regardless of age. As an individual’s health may change by a life-­ threatening condition (e.g., cancer, HIV/AIDS) and/or life-changing situations (e.g., death, divorce, burnout), one’s personal awareness to his or her own mortality or immortality increases and expands outwardly. This theory is applicable to a wide array of nursing practice areas, such as depression in middle-aged adults aged 25 to 64 (Ellerman & Reed, 2001) and elders’ (aged 53 to 79) perceptions of the role of group psychotherapy. Other researchers have used the theory to determine the effectiveness of nursing interventions or assess potential solutions in



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helping individuals cope, such as bereaved individuals who created AIDS quilt panels (Kausch & Amer, 2007) and cases of burnout in oncology and hospice nurses (­Hunnibell et al., 2008). The theory is easily operationalized in practice by utilizing the Self-Transcendence Scale (STS). The STS is a one-dimensional scale with 15 statements that measures experiences including a search for meaning, expanded boundaries, new perspectives and openness, and a concern for the well-being of others (Hunnibell et al., 2008). The responses are scored on a 4-point Likert scale of 1 (not at all) to 4 (very much), and the overall score is obtained by adding the scores and dividing the number by the total number of responses to establish validity and reliability. The study of the Theory of Self-Transcendence in practice using the STS tool has been shown to explain and predict the relationship between self-transcendence and improved quality of life as demonstrated in the following studies. It was used to describe the relationship of HIV patients’ quality of life and self-transcendence ­(Mellors, Riley, & Erlen, 1997; Ramer, Johnson, Chan, & Barrett, 2006) and in patients suffering from breast cancer (Coward, 2003). It was further demonstrated by looking at activities or strategies to promote or improve the patient’s level of self-­transcendence (intrapersonal, interpersonal, and transpersonal), including activities and strategies used in studies exploring the use of support groups, meditative/spiritual activities, and quality of life in patients with HIV and cancer (Coward, 2004). The theory guided the development of the research question in the majority of the research studies. The most prevalent research questions focused on the relationship of self-transcendence to variables such as disease condition, psychosocial capacity or event, construct, and nursing intervention. Common assumptions of SelfTranscendence Theory used in research include that self-transcendence is preceded by a life-threatening or life-changing event and that vulnerable individuals can either find meaning out of the event and cope effectively or fail to cope if interventions are not instituted. Additional assumptions of the theory have implications for nursing practice where nurses can utilize interventions, such as journaling, to help patients achieve well-being. Nurses can also utilize this theory for themselves to overcome burnout from their work environment. The theory is oriented to outcomes that are critical to vulnerable patients who are facing mortality (i.e., terminal illness) or dealing with psycho-socio-economic situations affecting one’s mental well-being. It allows for patients’ individual life experiences through illness or loss to be ascertained, as well as the relationship between these experiences and the nursing interventions or self-help strategies that the patients institute to cope and achieve well-being. Using the evaluative criteria by Fawcett (1999, 2005), additional information of previously mentioned research studies is discussed further in Table 16.1.

Relationship OF THE THEORY to prior research in nursing In 1993, Coward and Lewis explored self-transcendence in women and men with AIDS (Reed, 2012). In addition, Coward focused on how middle-aged adults diagnosed with serious illness, advanced cancer, and HIV confronted their mortality. According to Reed (2012), researchers such as Mellors, Riley, and Erlen (1997); C ­ oward (2005); and Ramer, Johnson, Chan, and Barrett (2006) have found a significant relationship

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Table 16.1 Evaluative Criteria and Use of Self-Transcendence Theory in the Study Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

Reed’s Theory of Self-Transcendence is a developmental process applicable to any person, regardless of age. As one’s life situation changes through a life-threatening condition (e.g., cancer, HIV/AIDS) and/or lifechanging situations (e.g., death, divorce, burnout), one’s personal awareness to his or her own mortality or immortality increases and expands outwardly. While in this process, individuals cope and search for new meaning and perspectives in order to achieve a sense of well-being. Several researchers have applied the theory to all ages: middle school boys ages 11 to 14 who experienced bullying and where self-transcendence is identified as part of the healing pattern (Willis & Griffith, 2010); depression in middle-aged adults 25 to 64 (Ellerman & Reed, 2001); elders’ perceptions of the role of group psychotherapy ages 53 to 79. Other researchers have used the theory to determine the effectiveness of nursing interventions or assess potential solutions in helping individuals cope: bereaved individuals who created AIDS quilt panels (Kausch & Amer, 2007); burnout in oncology and hospice nurses (Hunnibell, Reed, Quinn-Griffin, & Fitzpatrick, 2008). Nurses can play a role in helping patients cope with life-threatening or life-changing conditions, utilizing the Theory of SelfTranscendence, which eventually leads to a sense of well-being.

2.

Is it readily operationalized?

Multiple researchers have used the Self-Transcendence Scale (STS) to measure the concept of self-transcendence where its construct validity and reliability have been established. Depending on the focus of the study, the scale’s Cronbach’s alpha coefficient ranges from 0.80 to 0.93 as reported by Reed. The STS is a one-dimensional scale with 15 statements that measures experiences including a search for meaning, expanded boundaries, new perspectives and openness, and a concern for the well-being of others ­(Garcia-Romeu, 2010; Hunnibell et al., 2008). The responses are scored on a 4-point Likert scale of 1 (not at all) to 4 (very much). The overall score is obtained by adding the scores and dividing this number by the total number of responses.

3.

How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it relates?

The theory has been used to describe the relationship of HIV patients’ quality of life and self-transcendence (Mellors, Riley, & Erlen, 1997; Ramer, Johnson, Chan, & Barrett, 2006); breast cancer patients (Coward, 2003). Activities or strategies to promote or improve the patient’s level of self-transcendence (intrapersonal, interpersonal, and transpersonal) have been used in studies exploring the use of support groups, meditative/­ spiritual activities, and quality of life in patients with HIV and cancer (­Coward, 2004).

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

The theory relates to and addresses the research hypotheses in its description and explanation of the relationship between patients’ coping abilities, quality of life, the usefulness of support groups, and use of selfhelp interventions (e.g., journaling, meditation, prayer).

(continued)



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Table 16.1 Evaluative Criteria and Use of Self-Transcendence Theory in the Study (continued ) Questions for evaluation

Responses to questions

5.

Does the theory flow from the research question?

The theory guided the development of the research question in the majority of the research studies. The research question that is asked most of the time is on the relationship of self-transcendence to variables such as disease condition, psychosocial capacity or event, construct, and nursing intervention.

6.

Does the theory address the primary and secondary research questions?

Several studies have either two or more research questions. In the study of hospice and oncology nurses, the level of self-transcendence is measured in both groups to validate if there is a difference and its relationship to burnout. In studying the disease progression of individuals with HIV, the questions are explored if demographic and cultural factors, HIV progression, and clinical symptoms can affect the level of self-­transcendence or spirituality, perceived or not.

7.

Are the assumptions congruent with the assumptions that are made for research?

The assumptions are congruent depending on the research study. Common assumptions are (a) self-transcendence is preceded by a life-threatening or life-changing event, (b) vulnerable individuals can either find meaning out of the event and cope effectively or fail to cope if interventions are not instituted, (c) nursing interventions can help patients achieve well-being through self-transcendence, and (d) as a coping mechanism to help prevent burnout in nurses.

8.

Is the theory oriented to outcomes that are critical to patients?

The theory is oriented to outcomes that are critical for vulnerable patients as a result of facing mortality (i.e., terminal illness) or dealing with psychosocio-economic situations affecting one’s mental well-being. It allows for patients’ individual life experiences through illness or loss to be ascertained, as well as the relationship between these experiences and the nursing interventions or self-help strategies that the patients institute to cope and achieve well-being.

9.

Are tools available to test relationships of the theory or do they need to be developed?

A majority of the research studies utilize the STS tool. In other studies, STS is also used in combination with other measurements, such as Maslach Burnout Inventory Human Services Survey (MBI-HSS; used to measure burnout in health care workers). In studying patients diagnosed with HIV/ AIDS, STS is used in combination with Ferrans and Powers’s Quality of Life Index to determine the relationship of disease stage, quality of life, and self-transcendence (Mellors, Riley, & Erlen, 1997). The Spirituality Index of Well-Being was used in conjunction with STS to understand the correlation of self-transcendence and spirituality in the adult Amish (Sharpnack, QuinnGriffin, Benders, & Fitzpatrick, 2011). In the study of patients with breast cancer, multiple scales were utilized with STS: Purpose in Life Test, Affect Balance Scale, Profile of Mood States, Cognitive Well-Being Scale, Symptom Distress Scale, Karnotsky Performances Status, and Personal Resources Questionnaire (Coward, 2003). The Individualism–Collectivism Scale was utilized with STS to determine the development of wisdom and its relationship with self-transcendence. In a study of community-dwelling adults, the relationship of self-transcendence with health status and activities of daily l­iving (ADL) was measured using the Self-Rated Health Sub-index (SHS) and Lawton’s instrumental activities of daily living (IADL) (Upchurch, 1999).

Source: Fawcett (2005).

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between self-transcendence to the well-being or quality of life for persons with HIV/ AIDS. She also described Diener’s study in 2003 examining the effectiveness of personal narrative as an intervention for enhancing self-transcendence in women with HIV using a randomized clinical trial. Another phenomenological study by Coward in 1995 described the lived experience of self-transcendence in a diverse group of patients with AIDS (people with AIDS [PWA]). The study showed that self-transcendence is exhibited by individuals reaching out for help (to family, clergy, support groups) and helping others; acceptance of the closeness of death creates a sense of urgency to prioritize and participate in meaningful activities and leave a legacy (Mellors, Coontz, & Lucke, 2001). The growth of computer-mediated communication, such as a computer-­mediated self-help (CMSH) group, creates a new way of social contact, linking and connecting individuals with shared interests, goals, and values (DeSouza & Dutta, 2008). In a study done by Smith and Rapkin in 1995, 40% of people living with HIV/AIDS (PLWHA) have unmet needs for social interaction (Coursaris & Liu, 2009). “In light of the social conditions of prejudice and discrimination, the Internet can be a feasible, acceptable, and promising source of information and emotional support for PLWHAs” (Coursaris & Liu, 2009, p. 912). These authors also described Reeves’s study in 2000 examining the Internet use of HIV-positive individuals and its impact on their coping abilities. Through the Internet, individuals acquire more HIV/AIDS information, augment their social support, and facilitate coping by helping others. Lesbian, gay, bisexual, and transgender (LGBT) individuals suffer social, emotional, and psychological challenges in addition to the physically debilitating effects of HIV/AIDS throughout their lifetime. However, there is limited research between the relationship of self-transcendence in reducing high-risk behaviors of LGBT individuals and the effectiveness of CMSH groups (e.g., mailing lists, Internet newsgroups, discussion/bulletin boards/forums, live chat rooms) compared to traditional support in promoting their mental well-being. Hunnibell and colleagues (2008) conducted a descriptive comparative study between oncology nurses and hospice nurses to determine if there is a difference with the level of self-transcendence and the relationship of self-transcendence with burnout for both groups. The results of the study showed that both oncology and hospice nurses have high mean STS scores, but hospice nurses have higher levels of selftranscendence compared to oncology nurses. The study also showed that younger workers are more prone to burnout than older workers and that age and years of experience were associated with higher STS and lower levels of burnout. Due to multiple social structural changes and shifts in the economic culture, more Taiwanese women are in the workforce. Therefore, the practice of caring for a family member at home has changed, and many more elders are sent to institutions for care. “There has been a growing concern about elder care in Taiwan as the number of people 65 years or over are expected to increase from 10% of the total population to 32.33% by 2051” (Department of Statistics, Ministry of Interior, Taiwan 2006). This led to a study that was designed to promote self-transcendence and positive attitudes toward institutionalized elders in a Taiwanese student nurse population. The study tested a creative-bonding intervention with the goal of promoting these students’ interest in caring for elders. “Traditional Taiwanese society has been an agebased hierarchy with high value placed on respect for elders. In the midst of global changes related to health care and the advancing age of patients, difficulties have been noted by educators in student–elder communication. This has also decreased



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the opportunity for children to interact with aging grandparents. It is felt that this and the lack of shared experiences may contribute to the feelings of discomfort with an older patient population. . . .” Reed’s Theory of Self-Transcendence was the foundation for the development of the creative-bonding intervention. Reed’ s theory suggests that, “creative endeavors alone or with others enhance life’s meaning and such activities may lead to self-transcendence” (Chen & Walsh, 2009, p. 206). Palmer and colleagues (2010) examined the relationship and levels of self-­ transcendence as well as work engagement in acute care staff registered nurses using a descriptive correlation study applying Reed’s Theory of Self-Transcendence. Work engagement has been defined in the literature as a positive and rewarding emotion while at work that is characterized by vigor, dedication, and absorption (Schaufeli & Bakker, 2004). Nurses who work in acute care settings are often exposed to death, dying, and suffering patients. These experiences by acute care staff nurses make them aware of their own mortality and were conceptualized by the researchers as indicators of vulnerability that were expected to have a positive association with self-transcendence (Palmer et al., 2010). The researchers predicted that self-transcendence was positively associated with well-being (engagement) in the acute care staff nurses while at work (Palmer et al., 2010). Palmer and colleagues (2010) found that there was a significant positive correlation between work-related awareness of their own mortality and their level of self-transcendence in acute care staff nurses, which supported the theoretical association between vulnerability and self-transcendence. This study also found that there was a positive association between self-transcendence and work-related wellbeing (engagement) in acute care nurses (Palmer et al., 2010). Implications for nursing identified by the researchers from the results of this study support the use of interventions by nursing leaders to help staff nurses self-transcend by reflecting on and sharing their experiences with human suffering and mortality (Palmer et al., 2010). Using Rogers’s Science of Unitary Human Beings as the foundation of the neotheoretical model for self-transcendence, humans are integral with the universe and the environment. This simultaneous interaction of persons with the environment has the potential to foster one’s well-being. Throughout a human being’s life span, a person experiences vulnerability that can either be a life-changing situation or a life-threatening condition. These can be in the form of birth, terminal illness, loss and suffering, or death and dying. As a result of this experience, individuals may be able to overcome these adversities and self-transcend intrapersonally, interpersonally, temporally, and transpersonally to achieve a state of well-being (Figure 16.1).

use of the theory in this research and practice The program goals and objectives of Healthy People 2020 (2012) are to expand the current psychologically based services for HIV-positive patients to include increased and modernized prevention services for the HIV population. Already exposed to a lifetime of stigma of living with HIV/AIDS, this population’s vulnerability can potentially increase their degree of resilience, coping competence, and sense of well-being as they adapt to the illness process. In addition, the program is also committed to decreasing HIV and sexually transmitted infections (STIs), increasing outreach, and promoting education for those at high risk in conjunction with the program’s goals. It will also focus on reducing barriers through improved community links and referral networks for care, treatment, access through new media, and prevention services for

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Part III  Theories Applied to Future Research and Practice Figure 16.1  Neotheoretical Model of Self-Transcendence Theory. E N V I R O N M E N T

H U M A N B E I N G S L I F E S P A N

U N I V E R S E

B E Y O N D

LifeChanging Siutation

V U L N E R A B I L I T Y

Birth Bullying Homelessness ALS Cancer HIV/AIDS Transplant Aging Loss/Suffering Grief/Dying Death

LifeThreatening Condition

S E L F T R A N S C E N D E N C E

Intrapersonal Interpersonal Transpersonal Ternporal

w E L L B E I N G

persons living with or who are at high risk of acquiring or transmitting HIV and/or STIs. Integrating Reed’s Theory of Self-Transcendence can assist the HIV population in assessing the psychological well-being of identified individuals. According to Kolmes (2012), “two thirds of American adults use social media sites such as Facebook, Twitter, Linkedin, and MySpace” (p. 606). Kolmes explained that the Pew Foundation has found 80% of Americans have looked online for health information, whereas 34% of Internet users and 25% of adults read someone else’s comments or experience of health and medical issues online. The use of technology-enabled social and community support and group interventions through CMSH groups allow HIV-positive individuals and other vulnerable populations, includung transplant patients or patients diagnosed with cancer or amyotrophic lateral sclerosis (ALS), a safe and open communication platform that promotes trust, privacy, acceptance, freedom to disclose with no pressure, and an opportunity to learn from other participants’ lived experiences. The CMSH social support activities can allow patients and their families to expand their personal boundaries inwardly through introspection, outwardly through listening and caring concern for others, and temporally by reflecting on their past experiences, building hope for the future, and strengthening their present situation (Coward, 2003). According to Coursaris and Liu (2009): A number of previous studies have identified some of the advantages that CMSH groups can offer: lack of stigmatization due to anonymity, easier openness or more candor due to social distance within the groups,



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availability and easier access that minimizes barriers of time and location, diversity of members’ perspectives, similarity of members’ experience, and a large amount of information and resources. (p. 912) The increasing use of social networking sites as a means of interaction has become a new style of communication and offers meaningful outreach. Pyschoeducational group interventions via computer-mediated communication can bring people together by creating, building, and maintaining close supportive relationships. Many mental health professionals access sites to connect socially and professionally with peers and networks as well as provide education to consumers of psychological services (Kolmes, 2012). The use of technology and its effectiveness in helping individuals cope and achieve well-being will require further investigation.

RECOMMENDATiONS FOR FuRTHER RESEARCH AND PRACTiCE Reed’s theory identified that individuals who experience vulnerable life events such as living with HIV or a terminal illness can promote the developmental processes that foster self-transcendence, well-being, and quality of life. Through social and community support via a CMSH group, individuals may improve their ability to cope with their existing conditions, increase their sense of well-being, and improve adherence to healthy behaviors and retention in care. However, the technological pace of development makes it difficult for professional health care workers to fully understand the ethical implications of activities in the digital world, especially for this highly vulnerable population. Trust is the basis of every patient–provider interaction, most especially for sensitive information shared by an HIV-positive patient. The main barriers for adopting CMSH groups and other social networks in health care are privacy, confidentiality, and security of the data. Although CMSH groups and other online platforms will transform nursing care delivery, better regulatory clarity and policy on how to strengthen encryptions need to be established to address the privacy and confidentiality of personal health information shared online (Costa, 2012). A study is recommended on the relationship of self-transcendence in vulnerable populations to improve mental health and reduce high-risk behaviors by utilizing computermediated communication, specifically in CMSH groups. Vulnerable populations who are able to achieve self-transcendence can accept their diagnosis and overcome their fear of death and the stigma of their disease. By allowing others to help through a CMSH group, patients can consciously be responsible for following health-promoting behaviors and reducing health-risk issues for themselves and others. Utilizing the STS and interview-guided questions (Table 16.2), nurses can design a qualitative study that explores HIV-positive individuals’ abilities in overcoming their adversity and coping with the physical and emotional suffering of HIV/AIDS. Using a computer-assisted personal interview versus a traditional face-to-face interview process can help decrease the impact of psychosocial factors associated with HIV/AIDS and reduce high-risk behaviors of this population. The use of this automated process can also be extended to other vulnerable populations suffering from depression as a result of their diagnosis or altered life situations.

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Part III  Theories Applied to Future Research and Practice Table 16.2  Interview Guide Questions   1. Tell me what it has been like for you living with AIDS.   2.  What keeps you going from day to day?   3.  What is the hardest part about living with this illness?   4.  What do you do to “bounce back”? How do you keep a positive attitude?   5. Think about the things that mean the most to you and tell me more about them.   6.  What has changed since you were diagnosed with AIDS?   7. Tell me how you spend your time. What is a typical day like for you?   8. Do you ever question why this happened to you?   9. How satisfied are you with your life? 10.  What are the most important things to you in your life today? Adapted from Mellors, Coontz, and Lucke (2001).

Additional recommendations include guiding nurses in the use of self-­ transcendence to help decrease burnout, increase retention, and promote engagement. Palmer et al. (2010) found that self-transcendence was positively related to work engagement in acute care staff nurses. They suggest that interventions such as journaling, reflecting, and caregiver support groups may help facilitate self-­ transcendence in nurses (Palmer et al., 2010). Future research using Reed’s Theory of Self-Transcendence may include examining different interventions that help facilitate self-transcendence in nurses.

Summary Reed’s (2012) Theory of Self-Transcendence, derived from Rogers’s key postulate of pandimensionality, is concerned with individuals’ self-awareness extending beyond their physical and temporal being. Reed posited that self-transcendence may be accelerated by perceived end-of-life experiences, and hypothesized that self-transcendence is positively associated with well-being. Empirical research supports the relationship of self-transcendence and well-being across the life span for those facing their own mortality or experiencing life-threatening or life-changing events. Research has also shown exposure to life stresses (vulnerability) has a positive relationship with self-transcendence and well-being. Nurses play an important role in fostering self-transcendence to help patients achieve well-being when facing their own mortality or dealing with life-changing events. Nurses, other health care professionals, and caregivers can experience self-transcendence and well-being through their experiences in caring for those who are suffering and/or exposed to death and dying. With further research, self-transcendence will continuously evolve as nurses utilize converging technologies like CMSH and social media as part of their support mechanism.



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References Chen, S., & Walsh, S. (2009). Effect of creative-bonding intervention on Taiwanese nursing students’ self-transcendence and attitudes toward elders. Research in Nursing & Health 32, 204–216. Costa, F. (2012). Social network, web-based tools and diseases: Implications for biomedical research. Drug Discovery Today, 1–10. Retrieved from http://www.sciencedirect.com.vlib. excelsior.edu/science/article/pii/S1359644612003595?# Coursaris, C. K., & Liu, M. (2009). An analysis of social support exchanges in online HIV/AIDS self-help groups. Computers in Human Behavior, 25, 911–918. Coward, D. D. (2003). Facilitation of self-transcendence in a breast cancer support group: II. Oncology Nursing Forum, 30(2), 291–300. doi:10.1188/03.ONF Coward, D. D., & Kahn, D. L. (2004). Resolution of spiritual disequilibrium by women newly diagnosed with breast cancer. Oncology Nurse Forum, 31(2), e24–e31. Coward D. D., & Kahn, D. L. (2005). Transcending breast cancer: Making meaning from diagnosis and treatment. Journal of Holistic Nursing, 23(3), 264–283. d’Aquili, E., & Newberg, A. B. (1993). Religious and mystical states: A neuropsychological model. Zygon: Journal of Religion and Science 28, 177–200. d’Aquili, E., & Newberg, A. B. (1996). Consciousness and the machine. Zygon: Journal of Religion and Science 31, 235–252. d’Aquili, E., & Newberg, A. B. (1999). The mystical mind: Probing the biology of religious experience. Minneapolis, MN: Fortress. Delio, I. (2003). Brain science and the biology of belief: A theological response. Zygon, 38(3), 575–583. Department of Statistics, Ministry of Interior, Taiwan. (2006). National Indicators of Interior Statistics. Retrieved July 25, 2008, from http://www.moi.gov.tw/stat/english/ index.asp Desouza, R., & Dutta, M. J. (2008). Global and local networking for HIV/AIDS prevention: The case of the Saathii e-forum. Journal of Health Communication, 13, 326–344. Dodd, M., Miaskowski, C., & Paul, S. (2001). Symptom clusters and their effect on the functional status of patients with cancer. Oncology Nursing Forum, 28(3), 465–470. Ellerman, C. R., & Reed, P. G. (2001). Self-transcendence and depression in middle-age adults. Western Journal of Nursing Research, 23(7), 698–713. Farren, A. T. (2010). Power, uncertainty, self-transcendence, and quality of life in breast cancer survivors. Nursing Science Quarterly, 23(1), 63–71. doi: 10.1177/0894318409353793 Fawcett, J. (2005). Criteria for evaluation of theory. Nursing Science Quarterly, 18(2), 131–135. Garcia-Romeu, A. (2010). Self-transcendence as a measurable transpersonal construct. Journal of Transpersonal Psychology, 42(1). Gordon, M. (2010). Learning to laugh at ourselves: Humor, self-transcendence, and the ­cultivation of moral virtues. Educational Theory, 60(6), 735–749. Healthy People 2020. (2012). Lesbian, gay, and transgender health. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25 Hunnibell, L. S., Reed, P. G., Quinn-Griffin, M., & Fitzpatrick, J. J. (2008). Self-transcendence and burnout in hospice and oncology nurses. Journal of Hospice and Palliative Nursing, 10(3), 172–179. Kausch, K. D., & Amer, K. (2007). Self-transcendence and depression among AIDS memorial quilt panel maker. Journal of Psychosocial Nursing, 45(6), 44–53.

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Part III  Theories Applied to Future Research and Practice Kolmes, K. (2012, September 17). Social media in the future of professional psychology. Professional Psychology: Research and Practice. Advance online publication. doi:10.1037/ a0028678 Levenson, M. R., Jennings, P. A., Aldwin, C. M., & Shiraishi, R. W. (2005). Self-transcendence: Conceptualization and measurement. International Journal of Aging and Human Development, 60(2), 127–143. Mellors, M., Riley, T., & Erlen, J. (1997). HIV, self-transcendence, and quality of life. Journal of the Association of Nurses in AIDS Care, 82, 59–69. Mellors, M. P., Coontz, P. D., & Lucke, K. T. (2001). Transcending the suffering of AIDS. Journal of Community Health Nursing, 18(4), 235–246. Newberg, A., d’Aquili, E., & Rause, V. (2001). Why God won’t go away: Brain science and the biology of belief. New York, NY: Ballantine. Palmer, B., Quinn-Griffin, M. T., Reed, P., & Fitzpatrick, J. J. (2010). Self-transcendence and work engagement in acute care staff registered nurses. Critical Care Nursing Quarterly, 33(2), 138–147. Ramer, L., Johnson, D., Chan, L., & Barrett, M. T. (2006). The effect of HIV/AIDS disease progression on spirituality and self-transcendence in a multicultural population. Journal of Transcultural Nursing, 17, 280–289. doi:10.1177/1043659606288373 Reed, P. G. (1996). Transcendence: Formulating nursing perspectives. Nursing Science, 9(1), 2–4. Reed, P. G. (2003). The theory of self-transcendence. In M. J. Smith & P. Liehr (Eds.), Middle range theory for nursing (pp. 145–165). New York, NY: Springer Publishing Company. Reed, P. G. (2009). Demystifying self-transcendence for mental health nursing practice and research. Archives of Psychiatric Nursing 23(5), 397–400. doi:10.1016/j.apnu.2009.06.006 Reed, P. G. (2012). Theory of Self-Transcendence. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing (3rd ed., pp. 1–46). New York, NY: Springer Publishing Company. Rogers, M. E. (1970). An introduction to the theoretical basis of nursing. Philadelphia, PA: F.A. Davis. Rogers, M. E. (1980). Nursing: A science of unitary man. In J. P. Riehl & C. Roy (Eds.), Conceptual models for nursing practice (2nd ed., pp. 329–331). New York, NY: Appleton-Century-Crofts. Rogers, M. E. (1994). Nursing science evolves. In M. Madrid & E. A. M. Barrett (Eds.), Rogers’ scientific art of nursing practice (pp. 3–9). New York, NY: National League for Nursing. Runquist, J. J., & Reed, P. G. (2007). Self-transcendence and well-being in homeless adults. Journal of Holistic Nursing, 25(1), 5–13. Schaufeli, W., & Bakker, A. (2004). Job demands, job resources, and their relationship with burnout and engagement: A multi-sample study. Journal of Organizational Behavior, 25, 293–315. doi:10.1002/job.248 Sharpnack, P. A., Benders, A. M., & Fitzpatrick, J. J. (2011). Self-transcendence and spiritual well-being in the Amish. Journal of Holistic Nursing, 29, 91–97. Teixeira, E. M. (2008). Self-transcendence: A concept analysis for nursing praxis. Holistic Nursing Practice (January/February), 25–31. Tornstam, L. (1996). Gerotranscendence: A theory about maturing into old age. Journal of Aging and Identity, 1, 37–50. Tornstam, L. (1997). Gerotranscendence: The contemplative dimension of aging. Journal of Aging Studies, 11(2), 143–154. Upchurch, S. (1999). Self-transcendence and activities of daily living: The woman with the pink slippers. Journal of Holistic Nursing, 17, 251–266.



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Ventner, H., & Ventner, E. (2010). Globalization and the psychology of the new world citizen: How the new global citizen compares to Maslow’s level of self-transcendence. International Journal of Interdisciplinary Social Sciences, 5(7), 29–35. Willis, D. G., & Griffith, C. A. (2010). Healing patterns revealed in middle school boys’ experiences of being bullied using Rogers’ Science of Unitary Human Beings. Journal of Child and Adolescent Psychiatric Nursing, 23(3), 125–132.

chapter 17

Theory of Human Caring Catrina Heffernan

The Theory of Human Caring is an evolving theory. It was first published in 1979. The purpose of this chapter is to present an analysis of the Theory of Human Caring as developed by Jean Watson. The Theory of Human Caring is presented by describing the historical development, the core concepts, and the relationships among the core concepts. It is analyzed using the framework proposed by Fawcett (2005). ­Furthermore, a neotheoretical theory is presented using the Theory of Human Caring to guide a study “on patients’ perceptions of caring in the emergency depart­ ment.” The external consistency of the theory is evaluated, and its usefulness in research, practice, administration, and education is explored. This is based on the premise that caring occurs between a nurse and patient by embracing the patient’s story. The Theory of Human Caring describes transpersonal caring and clinical caritas and thus fits the criteria as a middle range descriptive classified theory. It is designed to guide the evolving nurse in Caritas nursing. Watson has devoted her entire life’s career to the phenomena of human caring, as well as inner subjective feelings, emotions, and experiences. She has through her writings and teaching given theory, voice, languages, philosophical-scientific views, and even spiritual credibility to the human experience. The phenomenon and practice of human caring and healing are the essence of nursing practice and foundational to sustaining life itself.

BASIC DESCRIPTION OF THE THEORY The theory is based on the premise that caring is the essence of nursing. It is a human interactive process between the one giving care and the one receiving it (the Caritas nurse and the patient). It involves helping the patient to find meaning in order to promote or restore the patient’s harmony. It involves expanding the Caritas nurse’s own self-actualization. It is the central focus of nursing at the disciplinary level. Watson’s theory was conceived from her 1979 publication, Nursing: The Philosophy and Science of Caring, which began as class notes for a course she was developing for nursing students. This was at a time when care was largely defined by medicine’s

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paradigm and traditional biomedical science models. Watson’s work was shaped by her own philosophical, intellectual, and experiential background. Phenomenological psychology and philosophy, in particular the work of Rogers, Yalom, and Peplau, contributed to Watson’s thinking. Other philosophical and intellectual traditions influencing her were Kierkegaard, Whitehead, De Chardin, and Sartre. This work was organized around the 10 carative factors that provided a guide to frame the “Core of Nursing.” (Core refers to those aspects of nursing that actually potentiate therapeutic healing processes and relationships; they affect the one caring and the one being cared for [Watson, 1997].) Her second major work, Nursing: Human Science and Human Care—A Theory of Nursing (1988), helped address the conceptual and philosophical aspects that existed around nursing. The concept of transpersonal caring was introduced in this publication and was notably influenced by Lazarus and Gadow. This work builds on the 10 carative factors. The attention to language was an important aspect in this postmodern era. “Clinical caritas” and “caritas processes” are offered as a substitute for the carative factors and include a greater spiritual dimension. It also outlines the worldview and philosophical context in that any nurse–patient encounter can be considered a caring occasion wherein a caring moment can be created and experienced, depending upon the consciousness and philosophical orientation that is guiding the nurse (Watson, 1997). The New Dimensions of Human Caring Theory (Watson, 1988) allows the theory to evolve by making the latter aspect more explicit and linking the caring consciousness and caring field. Postmodern Nursing and Beyond (1999) embeds caring in a new paradigm that acknowledges the symbiotic relationship among humankind–­technology– nature and the larger, expanding universe. It includes the search for spiritual aspects of our being. Recent personal experiences have cemented Watson’s inclusion of the spiritual aspect to caring. Caring Science as Sacred Science (Watson, 2005) brings a sacred dimension to the theory of caring. Caring is guided by the ethical-moral philosophical scientific context. She proposes that we dwell in mystery and the infinity of Cosmic Love as the source and depth of all of life. Comparisons are made with Florence Nightingale’s work, as she also drew upon spiritual dimensions as a source of healing. Nursing: The Philosophy and Science of Caring (Watson, 2008b) is an expansion and updated version of the original text. Watson identifies the caritas literacy, which “includes an evolved and continually evolving emotional heart intelligence, consciousness, and intentionality and level of sensitivity and efficacy, followed by a continuing lifelong process and journey to self-growth and self-awareness” (p. 23). She advocates “that the nurse, working within this framework of caring literacy, can be ‘biogenic,’ that is life receiving for self and other and thereby more likely to engage in and experience a transpersonal caring-healing moment” (p. 27). The evolving development of Human Caring Theory is illustrated in Figure 17.1.

CORE CONCEPTS Watson’s theory comprises three core concepts: the clinical caritas processes, the transpersonal caring relationship, and the caring occasion/caring moment.



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Figure 17.1  Historical (evolving) development of the Theory of Human Caring.

2013 Evolving 2008 Caritas literarcy (competencies) 2004

1985 10 Clinical caritas processes (include spirituality) 1979 10 Carative factors 7 Basic assumptions

10 Caritas processes in caring science (generating new connections between caring and love)

Transpersonal caring relationship (guided by Transpersonal caring caritas consciousness) relationship Caring occasion/caring moment 11 Assumptions

Transpersonal caring relationship (guided by caritas consciousness) Caring occasion/caring moment 4 Caring science assumptions

4 Caring science assumptions

Clinical Caritas Processes The 10 carative factors were first introduced in 1979 (see p. 75, Chapter 9, “­ Nursing: Human Science and Human Care A Theory of Nursing”). The carative factors helped provide a framework for nursing phenomena. They remain the timeless structural core of the theory (Watson, 2008b). They were renamed the clinical caritas processes in keeping with Watson’s own evolution and future directions of the theory. Caritas processes include a greater spiritual dimension and can be interpreted or considered more openly (Watson, 2005). The first three caritas processes form the philosophical foundation for the science of caring. The remaining seven are informed by the first three. They exist and can be demonstrated within the interaction between the nurse and the patient and are tangible manifestations and embodiment of human caring (Watson, 2006). When the caritas processes are demonstrated, healing is potentiated. The caritas processes are the core activities that a nurse demonstrates in caring for patients. These are the activities that a nurse does subconsciously. However, the nurse may not be aware of them by name due to a lack of awareness and/or a lack of knowledge of the terminology of caring. There is also a lack of recognized knowledge of everyday practices that define the nurse. Caring is one of the central features within caring science. Caring science is an evolving philosophical-ethical-epistemic field of study grounded in the discipline of nursing and informed by related fields (Watson, 2004).

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Transpersonal Caring Relationship The transpersonal caring relationship characterizes a unique style of human care relationship. It is about the nurse protecting the human dignity of the patient as well as the deeper/higher self. The nurse’s caring consciousness is communicated to preserve and honor the patient’s embodied spirit, thereby preventing the patient from being reduced to the moral status of an object. The nurse’s caring consciousness and connection have the potential to heal since experience, perception, and intentional connection are taking place (Watson, 1999). Nursing is centered on helping the patient achieve a higher degree of harmony within mind, body, and soul; this harmony is achieved through the caring dialogue involving a transpersonal caring relationship. This demonstrates the nurse’s concerns toward the patient’s understanding and meaning about his or her own health care situation, for example, on admission to the hospital. The nurse’s caring consciousness becomes essential for connectedness to occur. This highlights the uniqueness of both the patient and the nurse, and the mutuality between the two individuals, which is fundamental to the nurse–patient relationship. According to Watson (2001), the nurse and patient both connect in mutual search for meaning and wholeness, and perhaps for the spiritual transcendence of suffering. This allows for one to reach deeper spiritual connection in promoting the patient’s comfort and healing. A transpersonal caring relationship is guided by an evolving caritas consciousness. Caritas consciousness, according to Watson (2008a), conveys a concern for the inner-life world and subjective meaning of another that is embodied in spirit. This is consistent with the works of Newman (1991) and Rogers (1970, 1994).

Caring Moment/Caring Occasion According to Watson (1988, 1999), a caring occasion is the moment when the nurse and patient come together in such a way that a moment for human caring is created. Both the nurse and patient, with their unique phenomenal fields, have the possibility to come together in a human-to-human transaction. For Watson (1988, 1999), a phenomenal field corresponds to the person’s frame of reference or the totality of human experience, consisting of feelings, bodily sensations, thoughts, spiritual beliefs, goals, expectations, environmental considerations, and meanings of one’s perceptions—all of which are based upon one’s past life history, one’s present moment, and one’s imagined future. The nurse connects at a spirit-to-spirit level with another. This moment is divine in that it is a focal experience in space and time and also a caring moment of connection, surpassing a sense of time and space as it has a field greater than the individuals who experience it (Watson, 2008a). Watson (1999) insists that the nurse needs to be aware of her own consciousness and authentic presence of being in a caring moment with her patient. The caring occasion becomes “transpersonal” when “it allows for the presence of the spirit of both—then the event of the moment expands the limits of openness and has the ability to expand human capabilities” (Watson, 1999, pp. 116–117). This demonstrates that the nurse’s well-being is also enhanced. As the nurse and patient become connected, both can become more spiritually actualized by creating a unique “time–space relationship” with each other. By being in the moment the nurse–patient relationship becomes more than the sum of the parts. The Theory of Human Caring focuses on the conceptual relationship between the caritas processes, the transpersonal relationship and the caring moment. The caritas processes are the attributes that characterize a transpersonal relationship



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in the caring moment. However, it is not a linear process but a creative process that allows interaction of multiple factors and sources of knowledge occurring in mutuality. The foundation of Watson’s theory is her definition of caring. Caring is a moral ideal demonstrated through caritas processes (interventions) that allow for contact between the subjective world of the experiencing person (Watson, 1985). She defines caring as a value and an attitude that has to become a will, an intention, or a commitment that manifests itself in concrete acts (Watson, 1985, p. 32). As the theory evolves, caring is viewed as a science that encompasses a humanitarian, human science orientation, human caring processes, phenomena, and experiences. This gives rise to the notion that there is a greater being—the spirit field of infinity. The relationship between the three concepts gives rise to a caritas nurse. As the nurse grows and evolves, it is hoped that one enters a more profound level of insight, personal/professional growth, understanding, and wisdom. The dynamic of transpersonal caring within a caring moment is manifest in a field of consciousness. The transpersonal dimensions of a caring moment are affected by the nurse’s consciousness in the caring moment, which in turn affects the field of the whole (Watson, 2004). This is when the nurse engages fully with the patient in the present moment, with each bringing his or her own experience and meaning to a “caring moment.” The strength of her theory lies in the importance devoted to the lived experience of both the patient and the caritas nurse; the unique dimension of mind, body, and spirit as a whole; and valuing multiple sources of knowledge. Thus, the theory has been used as the theoretical basis for a number of research studies spanning a wide range of clinical areas and populations. It has attracted transcultural and transdisciplinary research, as caring impacts all professionals who practice in the disciplines of health and education.

RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS THEORY Caring is an interdisciplinary field of study. Watson’s theory is applicable to all of the disciplines within health care and has been used in education, health care, and the arts and humanities. Examples of studies from other disciplines include an evaluation of a program (Schroeder & Neil, 1992; Smith, 1997), enhancing nursing as a career choice for pupils (Turner, 2011), facilitating the Magnet Recognition Program (Birk, 2007), and being an infertile woman in Turkey (Arslan Özkan, Okumu, Buldukogˇlu, & Watson, 2013).

RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS Watson refers to the metaparadigm concepts throughout her publications but uses words interchangeably in her theory, which can be confusing for the novice reader of Watson. Her interpretations have also changed over time due to the evolving nature of the theory; again, this can be misleading. Nevertheless, the human being, health, environment, and nursing are referred to throughout her publications.

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Watson defines the human being as a being-in-the-world who is viewed as greater than, and different from, the sum of his or her parts (Watson, 1988). Health is a subjective, inner-life world experience. It is a harmonious and united mind, body, and soul associated with congruence between perceived and experienced self. For Watson (1988, 1999), the phenomenal field is the environment. A phenomenal field corresponds to the person’s frame of reference or the totality of human experience consisting of feelings, bodily sensations, thoughts, spiritual beliefs, goals, expectations, environmental considerations, and meanings of one’s perceptions—all of which are based upon one’s past life history, one’s present moment, and one’s imagined future. Within the caritas literacy, the nurse is the environment. Caritas nursing is when the nurse increases her awareness of the deeper dimension of the energetic range. The caritas nurse engages authentically in her own caritas consciousness evolution, opening access to the life energy source from the left-­quadrant knowledge system, which results in concrete caring practices that are both physical and metaphysical in nature (Watson, 2008a).

THEORY ANALYSIS This section presents an analysis of Watson’s theory. It is analyzed using Fawcett’s (1999, 2005) evaluative criteria and the use of the Theory of Human Caring in the researcher’s own study. The analysis is based on nine questions (Table 17.1). Evaluating a middle range theory is about forming an opinion about how valuable this theory is in relation to its applicability in practice, research, education, and administration. According to Smith (2008, p. 295), the life of any theory is determined by the scientific community’s engagement with it. Therefore, it is pertinent that research is guided by theoretical frameworks so that the longevity of a theory continues in order for it to be tested and validated. The usefulness of caring to research is that questions related to the patient’s perceptions of meaning can be addressed with the inductive reasoning of qualitative inquiry. Quantitative inquiry can be carried out through deductive reasoning beginning with the framework, which guides the researcher to find meaning in nurse–patient relationships.

RELATIONSHIP OF THE THEORY TO PRIOR RESEARCH IN NURSING Empirical literature since the development of the theory has demonstrated how the Theory of Human Caring is being applied to many patient populations with varying health challenges in many different caring contexts throughout the world. Hospitals across the United States have implemented the Theory of Human Caring in practice in order to maintain Magnet Status (Clarke, 2009). Falk Rafael (2000) applied the theory as a conceptual framework for guiding community health nursing practices. Watson and Foster (2003) used it to transform professional practice. It has been used within a computerized clinical documentation system (Rosenberg, 2006). Quinn, Smith, Swanson, Ritenbaugh, and Watson (2003) demonstrated its application for assessing the impact of the healing relationships in clinical nursing. Suliman, Welmann, Omer, and Thomas (2009) demonstrate how the Theory of Human Caring is utilized in multicultural practice environments. They explored patients’ perceptions of important caring behaviors and those most frequently attended to by nurses.



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Table 17.1 Evaluative Criteria and Use of Theory of Human Caring Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

The theory focuses on caring as the individual, interactional process between the nurse and the patient and thus fits the current study, which focuses on patients’ perceptions of caring.

2.

Is it readily operationalized?

Yes, each concept (the Clinical Caritas Processes, the Transpersonal Caring Relationship, and the Caring Occasion/Caring Moment) can be measured directly. There is a multitude of studies in the literature where the Theory of Human Caring has been operationalized in the discipline of health care.

3.

How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it relates?

The theory has been used in many different situations across the globe. Empirical literature has demonstrated its utility for exploring caring in a variety of contexts from the perspective of patients: measuring patients’ perceptions of nurse caring (Wolf et al., 2004), the process of caring from nurses’ and patients’ perspective (Wolf et al., 1994), the relationship between nurse caring and patient satisfaction (Palese et al., 2011; Wolf et al., 2003), hospitalized surgical patients’ responses to caring (Coulombe et al., 2002), trauma patients with multiple injuries (Merrrill et al., 2012), predictors of patient satisfaction with inpatient hospital nursing care (Larrabee et al., 2004), patients’ and nurses’ perceptions of caring (­Papastavrou et al., 2012), institutionalized older adults’ perceptions of nurse caring behaviors (Marini, 1999), the importance of caring to cardiac patients (Gay, 1999), to women during childbirth (Manogin et al., 2000), to patients receiving care at an emergency department ­(Baldursdottir & Jonsdottir, 2002), to patients being cared for in a multicultural environment (Suliman et al., 2009), and to compare nurses’ and relatives’ perceptions of the importance of caring behaviors (O’Connell & Landers, 2008). From the perspective of nurses: the relationship between caring and burnout (Perry, 2010), nurse practitioners’ perceptions of their own caring behaviors (Brunton & Beaman, 2000; Green, 2004), to determine the effects of care and economics on nursing practice (Nyberg, 1990), to measure nurses’ self-reports of caring in practice settings (Coates, 1997), the relationship between nurses’ expression of caring and job satisfaction (Amendolair, 2012), and of nurses’ perceptions of being cared for in the hospital (Clerico et al., 2011). From the perspective of relatives: family members’ perceptions of caring (Hayes et al., 2010).

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

The theory relates to and addresses the research hypotheses in its description and explanation of the relationship between patients’ perceptions of caring behaviors. There is sufficient empirical literature regarding the relationships between the concepts to guide this study. (continued)

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Table 17.1 Evaluative Criteria and Use of Theory of Human Caring (continued) Questions for evaluation

Responses to questions

5.

Does the theory flow from the research question?

The question has the potential to expand knowledge relating to caring experiences of patients on admission to the emergency room. The theory relates to and addresses the research hypotheses in its description and explanation of the relationship between patients’ perceptions of caring behaviors in terms of the interactive processes between a nurse and a patient.

6.

Does the theory address the primary and secondary research questions?

The theory addresses the primary and secondary research questions, explores the patients’ perceptions of caring in the emergency room, and is the Theory of Human Caring is the most appropriate framework for exploring caring.

7.

Are the assumptions congruent with the assumptions that are made for research?

The assumptions are congruent with the assumptions that are made for the research in that caring consists of caritas processes that result in positive outcomes for both patient and nurse and the practice of caring is central to nursing.

8.

Is the theory oriented to outcomes that are critical to patients?

The theory is oriented to outcomes that are critical to patients. There is an abundance of empirical literature supporting the ­positive outcomes to patients utilizing the Theory of Human Caring (Merrill et al., 2012; Palese et al., 2011; Quinn et al., 2003).

9.

Are tools available to test relationships of the theory or do they need to be developed?

In the current study, the CBI (Wolf et al., 2004) will be utilized and supported by individual interviews.

Adapted from Fawcett (1999, 2005) and Watson (1999).

Other studies exploring caring across countries were undertaken by Palese et al. (2011). Ryan (2005) demonstrated the integration of the nursing theory with clinical practice across a multihospital health care system. The benefits far outweigh the barriers. Many benefits were realized by embarking upon this journey to integrate nursing theory with nursing practice. It supported the view that nurses have a unique role in health care. By creating a common language of nursing, the nursing practice was solidified and strengthened across the system. Bent (2005) explored its significance in creating caring change in a health care system. Amendolair (2012) examined the relationship between nurses’ expression of caring and job satisfaction, and Burston and Stichler (2010) reported on the relationship among compassion, satisfaction, nurse job satisfaction, stress, burnout, and compassion fatigue to nurse caring. A multitude of studies have been undertaken exploring nurses’ perceptions of caring. Studies by Green (2004) and Papastavrou et al. (2011, 2012) explored nurses’ perceptions of caring behaviors. Vandenhouten, Kubsch, Peterson, Murdock, and Lehrer (2012) identified factors impacting nurses’ perceived professional caring. Findings show that experience, hospital-based nurses, and those demonstrating greater familiarity with the Theory of Human Caring had higher caring scores. Merrill, Hayes, Clukey, and Curtis (2012) assessed how patients perceive caring behaviors of nurses. Zamanzadeh, Azimzadeh, Rahmani, and



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Valizadeh (2010) determined the caring behaviors that oncology patients per­ ceive as important. Mullaney (2000) described the essential structure of the lived experience of depressed women who felt being understood and having a way out was important. Findings in a study by O’Connell and Landers (2008) showed that nurses ranked interpersonal aspects such as a trusting relationship, teaching, expression of positive feelings, and existential spiritual forces low. The variable (critical care setting) may have had an effect on these findings, as interpersonal communication may not be considered important in this setting. These findings are also supported by Zamanzadeh et al. (2010) where the nurses ranked comforts and trusting relationships low. Greenhalgh, Vanhanen, and Kyngas (1998) also found that male nurses were less likely than female nurses to engage in interpersonal skills such as being accessible, forming trusting relationships, or performing comforting behaviors to their client group. The subscale Comfort, which incorporated talking to the patient and listening to the patient, was ranked high by nurses. Psychiatric nurses ranked talking to the patient as most important. There was an association between gender and this behavior. Comfort was ranked higher by men than by women. Overall, physical-based caring behaviors were ranked higher than affective behaviors. In a study by Iranmanesh, Axelsson, Savenstedt, and Haggstrom (2009), a close and mutual relationship between nurse and patient was seen as the foundation for caring. They found this closeness pleasant and rewarding. They also refer to the aspect of trusting as fundamental in building the caring relationship. There is a suggestion that this closeness could result from the nurses’ personal and professional experiences and on their own life stories. In a study by Brunton and Beaman (2000), there was a significant relationship between the variable length of time as a nurse and positive connectedness. The longer the nurse had been in practice, the more frequently he or she reported behaviors that made up the caring dimension of positive connectedness (Brunton & Beaman 2000). In order for a connection to occur between the nurse and patient, there needed to be an element of trust. According to Dahlberg, Drew, and Nystrom (2001), nurses practice their embodied knowledge when they care for patients. Gatsmans (1999) believes that it is inner beliefs and the professional context of nursing that determine the meaning a nurse gives to caring. Erci et al. (2003) evaluated the effectiveness of Watson’s Theory of Human Caring Model on the quality of life and blood pressure of patients with hypertension. The findings demonstrated a positive relationship between care given according to the Theory of Human Caring Model and increased quality of life of the patients with hypertension (decrease in patient’s blood pressure was also reported). It is recommended as a guide to nursing patients with hypertension. Clerico et al. (2011) examined the nurses’ perception of being cared for in the hospital work environment using a survey design. Cara (2003) explored caring within the working culture of clinical nurses. Findings revealed that caring is learned from both natural and professional sources. Duffy (2003) explored caring relationships and their effect to improve clinical patient outcomes. Turkel (2003) explored caring in the context of the caring interactions between nurse managers and staff nurses. Findings showed that nurse managers could enhance the caring of patients by demonstrating caring with their nursing staff. There is a dearth of research carried out on the positive effects of caring relations on patient outcomes when utilizing the Theory of Human Caring.

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USE OF THE THEORY IN THIS RESEARCH The theory focuses on the human component of caring and the interactional process between the nurse and the patient and thus fits the current study, which focuses on patients’ perceptions of caring. The significance of exploring caring in the context of the nurse–patient relationship is paramount for nursing and knowledge development. Nurses need to understand how human connection creates ease for the patient. This is especially important in the clinical sites due to the hectic nature and high turnover of the environment. This will assist the nurse to better enhance the caring quality of the nurse–patient relationship. The Theory of Human Caring is broadly based and therefore provides a focus for research questions. It addresses questions in relation to describing patients’ perceptions of caring. The Theory of Human Caring identifies the relationships among the core concepts and provides a structure for understanding the connections among the components. Each of the concepts (caritas processes, transpersonal caring, and caring moment) can be measured, and there are countless studies in the literature operationalizing this theory. It is the most frequently reported theory in the caring instrument literature that has informed the development of caring tools (Watson, 2009). To meet the criteria for the purpose of the current study, a blended approach of quantitative measurements of caring and qualitative methodologies will be utilized. In order to measure caring from Watson’s perspective (spiritual dimension), it is imperative that other concepts be included to assist in measuring “caring” in its totality. Fagermoen (1999) believes that the nurse–patient relationship is viewed through a spiritual and metaphysical lens in the Theory of Human Caring (Figure 17.2). ­Caring can happen all at once and/or at any time between two individuals. The theory is used to explore patients’ perceptions of caring behaviors in the context of the nurse–patient relationship in the emergency room. The theory has been used in studies exploring caring behaviors in many settings. A mixed methodology incorporating the Caring Behaviors Inventory (Wolf, Zuzelo, Goldberg, Crothers, & Jacobson, 2006) and a phenomenological method is an accepted and tested method for analyzing data. The Caring Behaviors Inventory tool is used to investigate nurse caring behaviors. Caring comprises the three attributes of interpersonal touch, connecting, and trust. Interpersonal touch occurs between a nurse and patient. The theory centers on the nurse’s ability to engage a patient to intentionally dialogue about what matters most to him or her about his or her health challenge on admission to the emergency room. However, this cannot be realized without the nurse embracing the caritas processes. Caring is about the patient’s need to feel connected with the nurse and to feel trusted and cared for. The concepts are intricately connected. Connecting is a central theme in nursing (Beck, 2001). Connectedness is broadly defined as the extent to which a person perceives that he or she has a significant, shared, and meaningful personal relationship with another person, a spiritual being, nature, or an aspect of one’s inner self (Hasse, Britt, Coward, Leidy, & Penn, 1992, p. 146). This assumes that connectedness is more than words, and it is through the nurse that this can be accomplished. A true caring connection is an empowerment message and exchange of the human spirit (Schwerin, 2004). The nurse connection is defined as the successful communication of nursing by a nurse, whereby the recipient of nursing can trust the message of nursing and respond to the message in its entirety (Schwerin, 2004). When a person is in the moment, “there is a profound



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Figure 17.2  The Theory of Human Caring.

Intentional Dialogue on Admission to Hospital

Transpersonal Caring Relationship

Caritas Nurse Practicing Within Clinical Caritas Processes

Caring Occasion/Caring Moment

Connecting With Self in Relation/Developing Story Plot

Creating Ease/ Movement Toward Resolving

shift in one’s relationship to thoughts and emotions, the result being greater clarity, perspective and objectivity and ultimately, equanimity” (Shapiro, Carlson, Astin, & Freedman, 2006). According to Mok and Chi Chiu (2004), the nurse–patient relationship evolves into a trusting and connected relationship when nurses are caring in both action and attitude. Trust is identified as the foundation for a therapeutic nurse–patient relationship (Meize-Grochowski, 1984). Sellman (2007) contends that care without trust is unappealing, even in life-threatening situations. Trust is the optimistic acceptance of a vulnerable situation, following careful assessment, in which the patient believes that the nurse has his or her best interests as paramount (Bell & Duffy, 2009). It is not possible for patients to trust all health care professionals. Nurses must be able to demonstrate competence and willingness to dialogue with the patient in order to gain this trust. The concepts of caring, interpersonal touch, connectedness, and trust are interrelated and not linear. The theory relates to and addresses the research hypotheses in its description and explanation of the relationship between patients’ perceptions of caring behaviors in terms of the interactive processes between a nurse and a patient. The question has the potential to increase knowledge and understanding, related to patients’ perceptions of caring in the emergency room. Therefore, the theory guided the development of the research question and hypotheses. The research ­question asked, “What are patients’ perceptions of caring in the [emergency room]?” by virtue of the

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fact that caring is a Theory of Human Caring; it was employed to guide and structure the study and allowed for a framework to be created for reviewing the literature. The theory addresses the primary and secondary research questions: (a) to explore the patients’ perceptions of caring in the emergency room, and (b) is the Theory of Human Caring the most appropriate framework for exploring caring? The assumptions of the theory are consistent with the proposed research. There is, however, a continued interest in the scientific community in developing more robust measurement instruments. The theory is oriented to outcomes that are critical to patients. There is an abundance of empirical literature supporting the positive outcomes to patients utilizing the Theory of Human Caring (Merrill et al., 2012; Palese et al., 2011; Quinn et al., 2003). Differences were found between patients in their perceptions of caring behaviors in many of the reviewed studies. The type of instrument used revealed differences between patients in the ranking of how important different nurse caring behaviors are considered to be. Studies using instruments like Care-Q, Caring Assessment Questionnaire, and Caring Behaviors Assessment tool showed that patients ranked physical-based caring behaviors higher than affective behaviors. The Caring Behaviors Inventory (CBI) and adapted versions were the most frequently used instrument in the studies reviewed. There is copious debate in the literature about measuring the concept of caring. Caring is considered an ethical worldview and thus may be challenging to measure in its totality. Caring behaviors can be measured quantitatively, unlike caring efficacy. This debate is compounded by the lack of consensus on the place of caring in nursing due to different conceptualizations of caring (Watson, 2009). Watson states that while caring may never be truly measured, the many measurement tools available support the notion of assessing and capturing the phenomenon of caring and its relationship to patient outcomes. There are currently 27 tools available (Table 17.2) to measure caring, noting that any measurement is only an indicator of something deeper (Watson, 2009, p. 7). This section briefly introduces the instruments developed and informed by ­Watson’s Theory of Human Caring and presents examples of their usage in nursing practice and research. The CBI is one of the earliest instruments developed that provides supporting evidence for empirical validation of Watson’s theory. The CBI has been used by at least 132 researchers from several countries and is the only tool in which caring is conceptualized as an interpersonal intervention. A shortened form of the CBI was developed in 2006 by Wu, Larrabee, and Putman. It is designed to assess attitudes and actions of caring behaviors in the nursing process from the nurse or patient perspective. Both have been successful in measuring patients’ perceptions of nurse caring (Wolf et al., 2004), the process of caring from nurses’ and patients’ perspective (Wolf, Giardino, Osborne, & Ambrose, 1994), the relationship between nurse caring and patient satisfaction (Palese et al., 2011; Wolf, Miller, & Devine 2003), the relationship between caring and burnout (Peery, 2010), nurse practitioners’ perceptions of their own caring behaviors (Brunton & Beaman, 2000; Green, 2004), hospitalized surgical patients’ responses to caring (Coulombe, Yeakel, Maljanian, & Bohannon 2002), trauma patients with multiple injuries who perceive caring (Merrill, Hayes, Clukey, & Curtis, 2012), family members’ perceptions of caring (Hayes, Merrill, Clukey, & Curtis, 2010), predictors of patient satisfaction with inpatient hospital nursing care (Larrabee et al., 2004), and patients’ and nurses’ perceptions of caring across six European countries (Papastavrou et al., 2012). There is significant empirical evidence that the CBI is a valid and reliable tool that takes the shortest length of time to complete.



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TABLE 17.2 Tools for Measuring Caring  Scale

Source

Caring Behaviors Inventory and new version, Caring Behaviors Inventory for Elders

Wolf (2004, 2006)

Caring Behaviors Assessment Tool

Cronin and Harrison (1988)

Nyberg Caring Assessment Scale

Nyberg (1990)

CAT, Cat-admin, and CAT-edu

Duffy (1992, 2002); Duffy, Hoskins, and Seifert (2007)

Caring Efficacy Scale

Coates (1996, 1997)

Caring Nurse–Patient Interactions Scale

Cossette, Cote, Pepin, Ricard, and D’Aoust (2006)

Caring Behaviors Inventory–Short Form

Wu, Larrabee, and Putman (2006)

Caring Factor Survey

Nelson, Watson, and InovaHealth (2008)

Caring Dimensions Inventory

Watson and Lea (1997)

Caring Attributes, Professional Self-Concept, and Technological Influences Scale

Arthur et al. (1999)

Care-Q and modified forms

Larson (1984); Lee, Larson, and Holzmer (2006)

Professional Caring Behaviors

Horner (1989, 1991)

Caring Ability Inventory

Nkongho (1990)

Caring Behavior Checklist and Client ­Perception of Caring Scale

McDaniel (1990)

Peer Group Caring Interaction Scale and Organizational Climate for Caring Questionnaire

Hughes (1993)

Caring Professional Scale

Swanson (2000)

Holistic Caring Inventory

Latham (1986, 1996)

Methodist Health Care System Nurse Caring Instrument

Shepherd, Sherwood, et al. (2000)

Relational Caring Questionnaires

Ray and Turkel (2000, 2007)

Family Caring Inventory

Goff (2002)

Nurse–Patient Relationship Questionnaire

Quinn et al. (2003)

Caritas Nurse Profile

Persky et al. (2008)

Caring Behaviors of Nurses Scale

Hinds (1988)

Adapted from Watson (2009).

The Caring Behaviors Assessment (CBA) was developed by Cronin and H ­ arrison (1988) to identify nursing behaviors perceived by patients to indicate caring. Based on Watson’s earlier works, it has been used by researchers across the globe to measure institutionalized older adults’ perceptions of nurse caring behaviors (Marini,

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1999), the importance of caring to cardiac patients (Gay, 1999), to measure women’s feelings during childbirth (Manogin, Betchel, & Rami, 2000), to measure patients receiving care at an emergency department (Baldursdottir & Jonsdottir, 2002), to measure patients being cared for in a multicultural environment (Suliman et al., 2009), and to compare nurses’ and relatives’ perceptions of the importance of caring behaviors (O’Connell & Landers, 2008). Nyberg’s caring assessment is based on attributes taken from the carative factors (Watson, 1979) and caring theorists such as Mayeroff and Noddings. It has been used to determine the effects of care and economics on nursing practice (Nyberg, 1990), develop and test a curriculum focused on complementary healing modalities, and evaluate the effectiveness of the program toward expanding professional nurses’ knowledge and clinical skills in caring-healing concepts and practices (Updike, ­Clevland, & Nyberg, 2000). The Caring Assessment Tool (CAT) developed by Duffy, Hoskins, and Seifert (2007) measures nursing care as perceived by patients. The Caring Efficacy Scale was designed to assess a person’s confidence in his or her own ability to express caring and establish a caring relationship with patients. It has measured nurses’ self-reports of caring in practice settings (Coates, 1997). Sadler (2003) measured the caring efficacy of baccalaureate students. It has recently been used to examine the relationship between nurses’ expression of caring and job satisfaction (Amendolair, 2012) and to examine student perceptions when nurses share their stories (Adamski, Parsons, & Hooper, 2009). The Caring Nurse–Patient Interactions Scale describes attitudes and behaviors that can be seen in clinical practice and measured by frequency, importance, ­satisfaction, competency, and feasibility. It has been used to describe what constitutes caring in nursing (Cossette, Cote, Pepin, Ricard, & D’Aoust, 2006). The Caring F ­ actor Survey examines the human attributes of caritas (Drenkard, 2008). Most recently, it was used to examine nurses’ perceptions of being cared for in the hospital (Clerico et al., 2011).

RECOMMENDATIONS FOR FURTHER RESEARCH There are many studies that can be undertaken related to the Theory of Human Caring, both from the perspective of the nurse provider and also from the recipients of care. The most productive way of exploring the complexity of caring is with both qualitative and quantitative research. It is extremely important that nurse scientists continue the refinement of the dimensions of caring and examine new ways of measuring these dimensions.

SUMMARY The analysis using the framework proposed by Fawcett (2005) provided an in-depth assessment of the Theory of Human Caring. It revealed that the Theory of Human Caring provides an ample framework toward exploring and understanding caring from the perspective of the patient, the health care professional, and the system. However, Watson’s Theory of Human Caring, and the empirical studies utilizing her theory as a framework, have made and continue to make a significant impact on caring science. The outcomes in relation to nurses (health care professionals), patients, and systems are contributing to the disciplinary knowledge of nursing and caring science.



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chapter 18

Transformational Leadership Robin Krinsky and Josiane Hickson

Leadership is lifting a person’s vision to high sights, the raising of a person’s performance to a higher standard, the building of a personality beyond its normal limitations. —Peter Drucker The term Transformational Leadership was first defined by Downton in 1973. However, it was the seminal works in 1978 of Burns on transformational and transactional leadership that were published in his book, Leadership. His Theory of Transformational Leadership increasingly gained popularity. Since then, much empirical research has been conducted supporting the need for leadership to become more transformational and less transactional (Bass, 1997). Changes in work environments, workforce characteristics, and economy are placing pressure on leaders to become more transformational and less transactional if they want to remain effective in their roles. The first nurse leader can be traced back to Florence Nightingale. She felt nurses could lead mankind to create mankind (Nightingale, 1874) and that there were three phases of character development: selfish indulgence, character of duty, and accordance of right (Welford, 2002). Due to the increasing workload demands required of nurses, collaborative efforts to work with multidisciplinary teams, commitment to service-oriented quality initiatives, and management of complex patient problems foster the need for a leader who supports, empowers, motivates, and inspires them. The purpose of this chapter is to present an analysis of Transformational Leadership and its application to nursing practice.

BASIC DESCRIPTION OF THE THEORY James MacGregor Burns based his theory of Transformational Leadership (TFL) on the research of political leaders. He analyzed the characteristics of leadership that each leader embodied and how they inspired and motivated their followers to a higher moral level of being. Burns identified Transactional Leadership (TAL) as one

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person taking the initiative to contact another for the purpose of an exchange for something valued: “leaders approach followers with an eye towards exchanging” (Burns, 1978, p. 4). He categorized the two types of leadership as separate and mutually exclusive. He defined TFL as “the result of a relationship of mutual stimulation and elevation that converts followers into leaders and may convert leaders into moral agents” (p. 4). The theory of TFL that has given way to an abundance of research is that of Bernard M. Bass and Bruce J. Avolio. They extended the work of Burns by defining the underlying psychological mechanisms of TFL and TAL. Bass and Avolio (1985) defined TFL in terms of how the leader affects his or her followers. Followers of transformational leaders feel trust, loyalty, admiration, and respect in order to be motivated to do more than they originally are expected to do. The goal of Transformational Leadership aims to motivate followers by making them more aware of the outcomes of their efforts to move the organization toward their goals. The impact of each individual on how they connect to the organization’s philosophy, vision, and shared values is critical. Burns described the process of TFL as “leaders and followers help each other to advance to a higher level of morale and motivation” (1978, p. 20). Transformational leaders have a positive impact on their followers by effectively communicating the meaning of these values, which eventually inspire their followers. A transformational leader enhances his or her follower’s performance through the establishment of a professional and/or personal connection. This gives the follower a sense of value and that his or her commitment and participation within the organization may have an impact on organizational goals. This connection allows followers to take ownership of a project and enhances one’s own performance, while moving toward the achievement of the organization’s goals. Bass (1985) applied Burns’s theory toward leadership within organizations. He felt that transactional leaders stress how to marginally improve and maintain the quantity and quality of performance, how to substitute one goal for another, how to reduce resistance to particular actions, and how to implement decisions (Bass, 1986). Burns (1978) referred to the values of TAL that involve promises or commitments that are exchangeable for trust and respect as modal values. Modal values attempt to bond leaders and followers to actualize the needs of both leaders and followers. The leaders control resources that are important to the followers, such as benefits and salary (Yukl, 1981). Rewards can be concrete as well as nonconcrete. The leaders possess control in this relationship since they have the power to reward or not to reward behavior based on outcomes. Conversely to the principles of TAL, Burns (1978) identified that transformational leaders: . . . attempt and succeed to raise colleagues, subordinates, followers, clients, or constituencies to a greater awareness to the issues of consequence. This heightening of awareness requires a leader with vision, self-confidence, and inner strength to argue successfully for what he sees is right or good, not for what is popular or acceptable according to established wisdom for that time. (p. 20) Therefore, the rewards were nontangible; rather, they were the satisfaction of goal attainment. There are three basic goals of TFL in organizations: helping staff develop and maintain a collaborative culture, fostering staff development, and helping people solve problems more effectively (Barine & Minja, 2012). Teaching how to perform more effectively is a function of the transformational leader’s involvement in



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collaborative goal setting as well as communication of organizational values and goals. An employee’s motivation for personal development is enhanced when he or she can set goals for his or her own growth. Transformational leaders need to have goals that are attainable for the employees and not unrealistic ones, which can cause the employee to be defeated. Transformational leaders engage followers to not only work harder but also smarter. They support employees to work together to develop better solutions rather than relying solely on leaders.

CORE CONCEPTS What are the characteristics that one must possess to be identified as a transformational leader? Transformational leaders are people who create and sustain significant change in performance, morale, motivation, and dedication of their followers, supporters, organizations, and within themselves. The major characteristics of Transformational Leadership include engendering trust, admiration, loyalty, and respect among followers through application of charismatic vision and behavior (Nayab, 2010). These leaders encourage their followers to pursue goals that go beyond their immediate self-interests. Transformational leaders motivate followers and other constituencies to do more than they originally expected to do as they strive for higherorder outcomes (Burns, 1978). Self-interested pseudotransformational leaders may impress their followers in the same way, but their own purposes are clearly different and are likely to be exploitative rather than uplifting (Bass, 1997). Transformational Leadership consists of four constructs known as the “4 I’s”: idealized influence, inspirational motivation, intellectual stimulation, and individual consideration. Idealized influence involves building trust and confidence with followers by becoming admired and respected. Transformational leaders behave in ways that make them role models for their followers. Idealized influence is suggestive of shaping followers’ perceptions of their leader’s power, confidence, and ideals of alignment around a shared purpose. Followers who support transformational leaders anticipate that those leaders will “do the right thing” and maintain high standards of moral and ethical conduct. Effects of idealized influence create loyalty, confidence, and commitment of followers. Leaders who exemplify inspirational motivation create enthusiasm toward a persuasive vision of the future. They also challenge followers toward high goals, expectations, and standards in an effort to reach their full potential. Leaders communicate a purposeful vision and how it can be achieved collectively as a group. Inspirational motivation stimulates enthusiasm for teamwork and collegiality toward a goal. Motivation requires persuasion of followers to transcend their own interests for the collective team or organizational interest to attain an envisioned goal. Transformational Leadership promotes change through intellectual stimulation by challenging and reassessing the status quo. Leaders should encourage excitement to identify innovative and creative ways to resolve routine functions or recurrent issues. Whether addressing existing problems or identifying new approaches to an idea, followers are supported regardless of outcome. Transformational leaders possess the ability to articulate a vision, provide an appropriate model, foster group goals, create high performance expectations, and provide intellectual stimulation (Spreitzer, Perttula, & Xin, 2005). The effects of intellectual stimulation encourage the suggestion of radical and controversial ideas without fear of punishment or ridicule.

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Transformational leaders appreciate the significance of how groups affect outcomes; however, leaders must pay attention to individualized consideration. Individuals have unique needs, abilities, and goals. It is imperative for leaders to listen attentively, support, provide opportunities for growth, educate, and mentor their followers. Logically, leaders who provide individualized consideration toward their followers drive followers toward increased personal growth and development as well as their confidence and morale.

Relationship of Transformational Leadership Theory to Transactional Leadership TAL differs from TFL; however, both types of leadership seek to attain an established goal. TAL involves exchanges between the leader and the followers. Transactional leaders engage their followers in a relationship of mutual dependence in which the contributions of both sides are acknowledged and rewarded (Kellerman, 1984). ­Additionally, Burns (1978) believed that transactional leaders tend to focus on task completion and employee compliance and rely heavily on organizational rewards and punishment to influence employee performance. TAL occurs when the leader rewards or disciplines the follower, depending on the adequacy of the follower’s p ­ erformance (Bass & Riggio, 2005). TAL includes three components necessary for ­ followers’ goal attainment: contingent reward, management by exception, and laissez-faire leadership. Contingent reward involves leaders identifying and assigning a task with a desired goal. Upon expression of clear expectations made by the leader, follower agreement is offered. Followers’ reward for performance is based on promised or actual rewards offered in exchange for satisfactory completion of an assignment. Leaders and followers exchange promises and resources for support of the leaders, arrange mutually satisfactory agreements, negotiate for resources, exchange assistance for effort, and provide commendations for successful follower performance (Bass, 1997). Contingent reward is primarily a tangible compensation. Based on contingent reinforcement, management by exception rewards or punishes as a result of a designated action. Leadership intervention occurs when a corrective action is necessary. Leaders who practice management by exception routinely provide negative feedback because they only initiate contact with subordinates when failures occur (Barbuto, 2005). Transactional leaders who follow the model of management by exception primarily become involved when followers fail to meet an expected goal or deviate from a prescribed plan. Such interventions may be either active management by exception or passive management by exception. The leadership style of management by exception stifles the growth and development of followers and perpetuates the status quo. Followers are inadvertently set up for failure. In active management by exception, the leader arranges to actively monitor deviances from standards, mistakes, and errors in the follower’s assignment and to take corrective action as necessary (Bass & Riggio, 2005). These leaders will often predetermine a punishment for specific failures. Errors or failures are captured in real time in order to address or rectify them immediately. Leadership interaction or intervention occurs solely when corrective action is required. In passive management by exception, leaders fail to intervene until problems become serious and wait to take action when mistakes are brought to their attention (Bass & Riggio, 2005). Passive leaders become involved only when necessary and allow



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TABLE 18.1 Transformational Versus Transactional Leadership Characteristics Transformational

Transactional

Idealized influence Inspirational motivation Intellectual stimulation Individual consideration

Contingent reward Management by exception Laissez-faire leadership

Leaders motivate followers to achieve goals that are beyond self-interest.

Leaders link action and rewards

Proactive, think about future, and think about new ways of approaching issues.

Reward and punishment; set goals for rewards

Leader inspires and stimulates others to achieve personal as well as organizational goals.

Reactive, think about present situation

Leaders create situations for followers to grow.

Leader has and exerts power over followers

Charismatic appearance

Give and take

maintenance of the status quo. Followers are not held to high standards or expected to go above and beyond their daily functions. The laissez-faire style of leadership, or lack thereof, involves avoidance or acceptance of responsibilities, minimal presence with followers, falls short in following through on significant issues, and offers no input during decision making. Laissezfaire leaders give their followers complete autonomy with little or no guidance and are inattentive to productivity or the necessary completion of duties (Barbuto, 2005). Historically, early research has shown that the laissez-faire leadership style has led to low productivity, resistance to change, and low quality of work (Argyris, 1954; Berrien, 1961; Murnigham & Leung 1976). A comparison of leadership characteristics can be found in Table 18.1.

RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS THEORY Various disciplines have examined the theory of TFL and its influence on its domain. Human resources, business management, organizational development, and social sciences have researched and tested the theory of TFL. Weber (1947) identified charismatic leadership as a special personality characteristic of superhuman or exceptional powers for a select few of divine origin and results in a person being treated as a true leader. These characteristics closely identify with what Burns and Bass believed to be a description of TFL. Since his definition, House (1977) has interpreted a charismatic leader as one who is capable of having a profound effect on his or her followers. He further expounds his view that leaders can influence their followers to go above and beyond expectations. Charismatic leaders have influence over followers by exhibiting certain behaviors. The essential attributes of a charismatic leader are showing sensitivity to the followers’ needs, demonstrating unconventional behavior, articulating a vision, taking personal

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risks, and showing the follower sensitivity to the environment. House and Shamir (1993) included articulating an appealing vision, emphasizing ideological aspects of the work, communicating high performance expectations, expressing confidence that subordinates can attain goals, showing self-confidence, modeling exemplary behavior, and emphasizing collective identity. Questionnaires have been developed to test charismatic theories. Four behaviors that may be involved in charismatic leadership have been developed and tested by Shamir, Zakay, Breinin, and Popper (1998): supporting, displaying exemplary behavior (role modeling), emphasizing ideology, and emphasizing collective identity.

Transformational Leadership and Organizational Culture Organizational culture is the manner in which employees learn behavior that has been established within the organization. It is a learned pattern of behavior, shared from one generation of members to the next (Deal & Kennedy, 1982). Culture is believed to include the organization’s values, visions, missions, and beliefs. Organizational culture affects how individuals interact with each other individually, as a group, and toward their stakeholders. In order for organizational culture to be affected, desired behaviors must be exemplified from leaders at the top of the hierarchy and cascaded to all the members of an organization. Leaders who are concerned about organizational renewal will seek to foster organizational cultures that are hospitable and conducive to creativity, problem solving, risk taking, and experimentation (Bass, 1999). The culture of an organization is the glue that holds the organization together as a source of identity and distinctive competence (Schein, 1992). The existence of a favorable and successful organization is predicated on the values and beliefs of the founders or creators of an organization. It is the desired expectation of founders that their values and beliefs will be continued by their successors to maintain an effective organization. Successive leaders have often viewed themselves as stewards of the organizational culture initiated by the founder. Leaders create mechanisms for cultural development and the reinforcement of norms and behaviors expressed within the boundaries of the culture (Bass & Avolio, 2011). However, the success of an organization‘s culture is supported and reinforced by its leadership, with the intent that followers will embrace the organization’s culture (values and beliefs) to be their own. An organization’s culture and leadership has a bidirectional causation relationship. The organization’s culture is developed mostly by its leadership; in turn, the culture of an organization can also affect the development of its leadership. In a highly innovative and satisfying organizational culture, transformational leaders are viewed as ones who build on assumptions, such as people are trustworthy and purposeful, everyone has a unique contribution to make, and complex problems are handled at the lowest level possible (Bass & Avolio, 2011). Additionally, leaders must have a deep understanding of the identity and impact of the organizational culture to communicate and implement new visions and inspire follower commitment to the vision (Schein, 1992). The goal of transformational leaders toward their followers within an organization is to encourage ownership/investment of the workplace, broaden a vision, clarify purposes, and support adaptation of the organization’s culture. Transformational leaders play a significant role in the development and maintenance of the culture of their organization; they not only have



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the vision but also the ability to get their employees to accept that vision as their own, thus developing the commitment to bring the vision into reality (Oakley & Krug, 1991). Aydogdu and Aasikgil (2011) believed that the success, survival, and competing power of an organization depends on the commitment of their members, support of individual developments, and employee participation. Creating an organizational culture is made possible with the guidance of a transformational leader. Few studies have been conducted related to organizational culture and Transformational Leadership. However, studies on Transformational Leadership and organizational culture have been conducted globally. In 2006, Xenikou and Simosi examined the relationship between TFL and organizational cultural orientations, as well as the effect of TFL and organizational culture on business unit performance. Their results showed that TFL had a positive effect on performance through goal achievement. Additionally, they noted that the process of TFL facilitates goaloriented behavior and task accomplishment through intellectual stimulation; in addition, new ways of framing and solving problems had a positive influence on performance. Nguyen and Mohamed (2011) investigated the influence of transformational and transactional leadership behaviors on knowledge management practices, and how it affects organizational culture in small-to-medium businesses in Australia. The results of this study did not find that there was any effectiveness of TFL on organizational culture; however, Nguyen and Mohamed noted that TFL can directly and indirectly enhance organizational innovation by creating a supportive organizational culture. Abbasi and Zamani-Miandashti (2013) investigated the role of TFL, organizational culture, and organizational learning in improving the performance of Iranian agricultural faculties and leading them to become learning organizations. Their findings supported that TFL and learning organizational culture improved the agricultural faculties performance, thereby transforming them into learning organizations. Carter, Armenakis, Field, and Mossholder (2012) investigated how team-focused TFL influences employee performance at lower organization levels where change is an integral part of ongoing operations. Analyses revealed that relationships between leaders and employees mediated the influence of TFL on employee outcomes and organizational behavior. A positive correlation was also noted during high frequency of change and the quality with task performance. The paucity of research in organizational culture and TFL lies within the nursing discipline, which suggests that this is an area that requires further investigation.

Gender Issues and Leadership Style Multiple studies have examined the relationship between gender and leadership style. The belief of “think manager-think male” could not be farther from what the research supports. A meta-analysis of over 45 studies that observed female and male managers were performed (Eagly, Makhijani, & Klonsky, 1992). Female leadership traits revealed characteristics of a transformational leader versus male leadership traits that were consistent with transactional leadership. Male leaders demonstrated behaviors of a contingent reward system that follows the behavior of managementby-exception and laissez-faire leadership styles. Women have been shown to outscore men in their leadership abilities to positively impact work outcome behaviors and

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all areas of TFL behaviors (Eagly & Carli, 2003). Due to the increasing demand for health care to become more interdisciplinary, women may be better suited for leadership roles. Although literature supports that women demonstrate more TFL behaviors, they have disadvantages in the workplace as well. Historically and ­stereotypically, men are seen as the dominant leaders in organizations. The characteristics of ­ambition and competency are more masculine in nature. Society views men as leaders. Looking at world leaders, the male presence is dominant (Sczeny, Bosak, Neff, & Schyns, 2004). Women, in contrast to men, are expected to exhibit ­behaviors that are associated with being nice, warm, nurturing, and caring. These traits do not match society’s expectations of leadership behavior. In order for women to be ­successful leaders, they must possess and exhibit behaviors associated with ­masculine characteristics such as ambition, authority, and power. As women aspire to leadership positions, they need to find a middle ground between not too m ­ asculine and not too feminine.

RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS Transformational Leadership nursing metaparadigm focuses on the relationships among the four concepts of person, environment, health, and nursing. These four concepts lead us to a better understanding of nursing and the TFL theory. Although TFL is utilized in nursing, it is not a nursing theory. TFL, as it relates to nursing metaparadigm concepts, will be excluded; however, the concepts will be explained as individual concepts. TFL theory involves the person, since he or she is the recipient of TFL. Burns (1978) described TFL as occurring when “two or more persons engage with o ­ thers in such a way that the leader and followers raise one another to high levels of ­motivation and morality.” The environment is the location as well as the atmosphere in which TFL is being practiced. Burns (1978) believed that TFL has the potential to motivate followers to satisfy higher level needs, such as self-esteem and self-­actualization. Influenced ­followers of transformational leaders find meaning and value in their work, and ­contribute significantly toward successfully accomplishing the vision and goals of their employing organization. The employee’s level of well-being is reflected in the person’s overall health. Burns’s (1978) view is that TFL makes a profound difference in the life of individuals and organizations. Through the promotion and cultivation of an environment of empowerment, stimulation, and guidance, the effects of TFL can affect followers, which results in the organization’s success. The relationship to the metaparadigm concepts can be found in Figure 18.1.

THEORY ANALYSIS TFL theory has been used in a number of disciplines, including health care disci­ plines. Thus, the theory has significance and usefulness in nursing research and ­practice. A number of measures have been developed and tested to operationalize the



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Figure 18.1  Metaparadigm of Transformational Leadership.

Person

TRANSFORMATIONAL LEADERSHIP

Health

Environment

concepts. These include the Multifactor Leadership Questionnaire (MLQ) that has become the gold standard of measure for TFL by providing behavior-based feedback to leaders at any level on areas of focus for one’s professional-development efforts in specific concrete behavioral terms. The MLQ provides specific feedback that can be used for individual, team, and organizational development, as well as individual counseling. The theory has direct application to both nurse and patient outcomes. Examples of outcomes that can be related to the theory are nurse retention and patient satisfaction. The evaluation of the TFL model can be found in Table 18.2.

RELATIONSHIP OF The THEORY TO PRIOR RESEARCH IN NURSING Managerial Leadership and Nurse Retention/Satisfaction Effective nursing leadership positively influences job satisfaction when there is an open discussion of ideas among staff and managers (Gray-Toft & Anderson, 1985). It has been demonstrated that nurse managers and nurse executives perceive that they demonstrate a high incidence of TFL behaviors, although this perception often does not match staff nurses’ perception of those leaders (Dunham & Klafehn, 1990; Dunham-Taylor, 2000). Furthermore, evidence suggests that nurses do not leave hospitals, they leave managers (Ribelin, 2003). Nurses’ satisfaction with their manager’s leadership style is critical to overall nurse satisfaction and turnover within an organization. Effective nursing leadership behaviors impact upon the retention of nurses as well as their job satisfaction. Kleinman (2004) described the perceptions of ­managers’ leadership behavior on staff nurse turnover and job satisfaction. She found that both TFL and TAL have been perceived behaviors by staff nurses. She was unable to conclude which of these behaviors contributed most to staff nurse retention. However,

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Table 18.2 Evaluative Criteria and Use of Transformational Leadership (TFL) Theory Questions for evaluation

Responses to questions

1.

Does the theory fit the research that you wish to do?

The theory developed by Burns (1978) introduced the concept of TFL as an ongoing process by which “leaders and followers raise one another to higher levels of morality and motivation” (p. 20). TFL theory is used in social sciences, organizational leadership and development, business and industry, health care, academia, and the military.

2.

Is it readily operationalized?

TFL begins with awareness of one’s own thoughts and feelings, and how they affect personal actions and the states of others. True leadership cannot be operationalized until one exercises self-reflection.

3.

How well has the theory performed at describing, predicting, and/or explaining the phenomena to which it relates?

TFL has been applicable among a multitude of disciplines. This theory has been used to assess, evaluate, and effectuate the implementation of change in behavior within individuals and organizations.

4.

Does the theory relate to and address the research hypotheses in its description and explanation?

The research can guide the research and practice in nursing.

5.

Does the theory flow from the research question?

There are a number of research questions that can be answered.

6.

Does the theory address the primary and secondary research questions?

The theory can address both primary and secondary questions.

7.

Are the assumptions congruent with the assumptions that are made for research?

Until the specific research questions are developed, it is not possible to evaluate the underlying assumptions.

8.

Is the theory oriented to outcomes that are critical to patients?

TFL theory focuses on managerial leadership styles, which have a direct effect on nurse retention and satisfaction. Therefore, these nursing effects have an impact on patient outcomes.

9.

Are tools available to test relationships of the theory or do they need to be developed?

There are several other tools in existence, although few as prevalent or comprehensive as the Multifactor Leadership Questionnaire (MLQ). They are: 1. Transformational Leadership Behavior Inventory (TLBI; Podsakoff, MacKenzie, Moorman, & Fetter, 1990) 2. Leader Assessment Inventory (LAI; Burke, 1994) 3. Transformational Leadership Questionnaire (TLQ; AlimoMetcalfe & Alban-Metcalfe, 2001) 4. Global Transformational Leadership Scale (GTL; Carless, Wearing, & Mann, 2000) (continued)



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Table 18.2 Evaluative Criteria and Use of Transformational Leadership (TFL) Theory (continued) Questions for evaluation

Responses to questions

5. 15 item rating scale (Rafferty & Griffin, 2004) 6. Follower Belief Questionnaire and the Attributes of Leader Behavior Questionnaire (Behling & McFillan, 1996) 7. Conger-Kanungo Scale (Conger & Kanungo, 1987) 8. Leadership Practices Inventory (LPI: Posner & Kouzes, 1998) Adapted from Fawcett (2005).

the TAL style of management by exception contributed to the most s­ ignificant staff turnover (r = .26; p = .03). She noted that when managers performed a self-assessment of leadership and compared that to staff nurses’ perception of leadership, the managers perceived that they had a high frequency of TFL style, but the staff nurses’ perception did not concur. However, does this prompt further investigation whether or not the managers were truly transformational based on staff perception?

Transformational Leadership in Magnet® Organizations The American Nurses Credentialing Center (ANCC) Magnet Recognition program identifies and emphasizes that chief nursing officer (CNO) leadership styles need to be transformational to influence quality. TFL, a Magnet Model component, serves as a guide and resource for best practices as it relates to organizational leadership and development. Magnet-recognized organizations today strive for stabilization (American Nurses Credentialing Center, 2012). This is one of the major pillars of the program and is evaluated in order to achieve the designation of Magnet status. The Magnet model links structure, process, and outcomes by synthesizing multiple sources of evidence that can lead to positive nurse, patient, and clinical outcomes. Drenkard (2012) has identified that these sources of evidence require a new way of thinking from leadership so they reach beyond self-interest and allow the entire nursing team to belong. In a dynamic health care environment, organizations can become unpredictably destabilized. A nursing leader who can strategically plan, advocate for nursing, and communicate the organizational vision can positively impact positive staff and patient outcomes. Drenkard (2012) further elaborated: As health care changes key elements of nursing leadership practice for the future will include serving as a leader to transform care models, the ability to foster autonomy of practice in care areas, creating systems of care based on evidence-based practice, collaboration, fostering lifelong learning among nurses, and strategically managing resources. (p. 153) The TFL behaviors of CNOs have not been widely researched. Porter-O’Grady (2009) looked at the self-perceptions of chief nurse ­executives’ leadership practices in Magnet and non-Magnet organizations. He used the Leadership Practice Inventory Subscale (LPI-s), which looks at the f­ollowing five subscales: model the way, inspire a shared vision, challenge the process, enable others to act, and encourage the heart. The LPI (Kouzes & ­Posner, 1990), measures five leadership practices that

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were identified by Kouzes and Posner (1987): Challenging the Process, Inspiring a Shared Vision, Enabling Others to Act, Modeling the Way, and Encouraging the Heart. These six items are used to measure each of the five scales and the total ­number of items is 30. The LPI was developed through a triangulation of qualitative and quantitative research s­ tudies and includes statements describing various ­leadership actions and behaviors (Tourangeau & McGilton, 2004). This i­nstrument has proven quite robust in assessing individuals’ leadership behaviors and in ­providing feedback useful for developing and enhancing leadership capabilities. Of the 161 nurse executives s­ urveyed, there were no statistically significant differences in the self-perception of leadership practices of chief nursing executives in ­Magnet as ­ compared to non-Magnet institutions (Porter-O’Grady, 2009). Overall CNOs attained high scores in self-perceptions of leadership practices whether or not they were in ­Magnet organizations. Clavelle, Drenkard, Tullai-McGuinness, and Fitzpatrick (2012) looked at the TFL Inventory Practices of 225 CNOs and found the top two TFL practices of CNOs in Magnet organizations are (a) enabling others to act and (b) modeling the way. In addition, this was the first study to examine the TFL practices and find a relationship between the age of the CNO, the length of time in the position of CNO, and the direct impact of his or her TFL practices. CNOs who were older and had more experience as a CNO in a Magnet organization were able to recruit others in sharing a common vision. The more tenured CNOs revealed stronger TFL styles and follower inspiration. Clavelle and colleagues (2012) also found that CNOs who had doctoral degrees had stronger TFL styles. Today’s ever-changing health care environment seeks CNOs and leaders who can guide and support nurses at the bedside through challenges and changes that are brought about by health care reform. Nursing research has focused on qualities and behavioral characteristics of effective, successful leaders, and the traits necessary to become a transformational leader. However, there is less transparency in nursing research related to followers’ perceptions and views from a qualitative and quantitative perspective. This is an area that needs to be more closely investigated in order to view leadership from all dimensions.

RECOMMENDATIONS FOR FURTHER RESEARCH AND PRACTICE Additional research is needed in the areas of nurses’ satisfaction and retention as influenced by leadership styles. Both nurses’ satisfaction and retention are a reflection of nurse engagement and these components are essential in Magnet certification. TFL style is an essential component of that model. Also, there is very little to no research on just how TFL works, especially in the domain of nursing where a large gap exists. More research can be found in the literature of business, psychology, and organizational culture than in nursing. Areas of interest for further research within leadership include the effects of Transformational Leadership and merging/acquisitions of organizations. There has been a surge of mergers of health care organizations with the prediction of over 1,000 more within the next seven years (Creswell & Abelson, 2013). It has yet to be determined which types of leaders will endure during mergers and acquisitions. More research on successful mergers/acquisitions may predict which behavior styles one must possess in order to survive.



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SUMMARY The purpose of this chapter was to present an analysis and evaluation of TFL Theory, based on historic as well as recent publications of this theory and its applications to nursing. Understanding the differences between the various types of leadership is essential in developing leaders, as well as moving one’s organization forward. There is no single leadership theory that includes all behaviors of leadership. Effective leaders not only possess dominant TFL qualities, but also transactional qualities. The boundaries between transactional and transformational behaviors are fragile, and leaders can find themselves flowing from one style to another in the complexity of health care. In the words of James MacGregor Burns, “Leadership is one of the most observed and least understood phenomena on earth” (Burns, 1978, p. 2).

REFERENCES Abbasi, E., & Zamani-Miandashti, N. (2013). The role of Transformational Leadership, organizational culture and organizational learning in improving the performance of Iranian agricultural faculties. Higher Education, 66(4), 505–519. doi:10.1007/s10734-013-9618-8 Alimo‐Metcalfe, B., & Alban‐Metcalfe, R. J. (2001). The development of a new transformational leadership questionnaire. Journal of Occupational and Organizational Psychology, 74(1), 1–27. American Nurses Credentialing Center (Ed.). (2012). Application manual: Magnet Recognition program. Silver Spring, MD: Author. Argyris, C. (1954). Human relations in a bank. Harvard Business Review, 32(5), 63–72. Aydogdu, S., & Aasikgil, B. (2011). The effect of Transformational Leadership behavior on organizational culture: An application in pharmaceutical industry. International Review of Management and Marketing, 1(4), 65–73. Barbuto, J. E. (2005). Motivation and transactional, charismatic, and Transformational Leadership: A test of antecedents. Journal of Leadership and Organizational Studies, 11(4), 26–40. doi: 10.1177/107179190501100403 Barine, A. K., & Minja, D. (2012). Transformational corporate leadership. Wake Forest, NC: Integrity Publisher. Bass, B. M. (1985). Leadership and performance beyond expectations. New York, NY: Free Press. Bass, B. M. (1986). Leadership: Good, better, best. Organizational Dynamics, 13(3), 26–40. Bass, B. M. (1997). Does the transactional-Transformational Leadership paradigm transcend organizational and national boundaries? The American Psychologist, 52(2),  130–139. doi: 10.1037/0003-066X.52.2.130 Bass, B. M. (1999). Two decades of research and development in Transformational Leadership. European Journal of Work and Organizational Psychology, 8(1), 9–32. Bass, B., & Avolio, B. (1985). The Multifactor Leadership Questionnaire. Palo Alto, CA: Consulting Psychologists Press. Bass, B. M., & Avolio, B. J. (2011). Transformational Leadership and organizational culture. Retrieved from http://lsahulka.typepad.com/blog/2011/05/transformational-leadership-andorganizational-culture.html Bass, B. M., & Riggio, R. E. (2005). Transformational Leadership. New York, NY: Lawrence Erlbaum. Behling, O., & McFillen, J. M. (1996). A syncretical model of charismatic/Transformational Leadership. Group and Organizational Management, 21(2), 163–191. Berrien, F. K. (1961). Homeostasis theory of groups—implications for leadership. In L. Petrullo & B. Bass (Eds.), Leadership and interpersonal behavior. New York, NY: Holt, Rinehart & Winston.

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Kouzes, J., & Posner, B. (1990). Leadership Practices Inventory (LPI): A self-assessment and analysis. San Diego, CA: Pfeiffer & Co. Murnigham, J. K., & Leung, T. K. (1976). The effects of leadership involvement and the importance of the task on subordinates’ performance. Organizational Behavior and Human Performance, 17(2), 299–310. Nayab, N. (2010). Characteristics of Transformational Leadership. Retrieved from http://www .brighthub.com/office/home/articles/71743.aspx Nguyen, H. N., & Mohamed, S. (2011). Leadership behaviors, organizational culture and knowledge management practices: An empirical investigation. Journal of Management Development, 30(2), 206–221. doi:10.1108/02621711111105786 Nightingale, F. (1874). Hand-written notes on addresses to probationers. England Bladd MSS45. Oakley, E., & Krug, D. (1991). Enlightened leadership. New York, NY: Fireside. Podsakoff, P. M., MacKenzie, S. B., Moorman, R. H., & Fetter, R. (1990). Transformational leader behaviors and their effects on followers’ trust in leader, satisfaction, and organizational citizenship behaviors. Leadership Quarterly, 1(2), 107–142. Porter-O’Grady, T. (2009). Creating a context for excellence and innovation: Comparing chief nurse executive leadership practices in Magnet and non-Magnet hospitals. Nursing Administration Quarterly, 33(3), 198–204. Posner, B. Z., & Kouzes, J. M. (1988). Development and validation of the leadership practices inventory. Educational and Psychological Measurement, 48(2), 483–496. doi:10.1177/0013164488482024 Rafferty, A. E., & Griffin, M. A. (2004). Dimensions of Transformational Leadership: Conceptual and empirical extensions. Leadership Quarterly, 15(3), 329–354. doi:10.1016=j. leaqua.2004.02.009 Ribelin, P. (2003). Recruitment and retention report: Retention reflects leadership style. Nursing Management, 34(8), 18–19. Schein, E. H. (1992). Organizational culture and leadership (2nd ed.). San Francisco, CA: Jossey-Bass. Sczeny, S., Bosak, J., Neff, D., & Schyns, B. (2004). Gender stereotypes and the attribution of leadership traits: A cross-cultural comparison. Sex Roles, 51, 631–645. doi:10.1007/ s11199-004-0715-0 Shamir, B., Zakay, E., Breinin, E., & Popper, M. (1998). Correlates of charismatic leader behavior in military units: Subordinates’ attitudes, unit characteristics, and superiors’ appraisals of leader performance. The Academy of Management Journal, 41(4), 387–409. Spreitzer, G. M., Perttula, K. H., & Xin, K. (2005). Traditionality matters: An examination of the effectiveness of Transformational Leadership in the United States and Taiwan. Journal of Organizational Behavior, 26(3), 205–227. doi:10.1002/job.315 Tourangeau, A., & McGilton, K. (2004). Measuring leadership practices of nurses using the leadership practices inventory. Nursing Research, 53(3), 182–189. Weber, M. (1947). The theory of social and economic organizations (T. Parsons, Trans.). New York, NY: Free Press. Welford, C. (2002). Transformational Leadership in nursing: Matching theory to practice. Nursing Management-UK, 9(4), 7–11. Xenikou, A., & Simosi, M. (2006). Organizational culture and Transformational Leadership as predictors of business unit performance. Journal of Managerial Psychology, 21(6), 566–579. doi:10.1108/02683940610684409 Yukl, G. A. (1981). Leadership in organizations. Englewood Cliffs, NJ: Prentice-Hall.

chapter 19

Theory of Empowerment Jean Marie DiNapoli, Deirdre O’Flaherty, and Mary Joy Garcia-Dia

Empowerment as a concept is frequently used throughout the literature by authors and researchers from many disciplines. Thus, it can be defined in various ways based on the discipline and the situational context. For the purposes of this chapter, the focal point of discussion is the influence of structural and psychological empowerment and its relationship to nursing—and specifically nurse managers. Nursing leaders have a large impact on maintaining the quality of nursing work environments (Cummings, MacGregor, & Davey, 2010), improving patient outcomes (Wong, Laschinger, & ­Cummings, 2010), promoting work engagement, and addressing burnout (Greco, Laschinger, & Wong, 2006; Laschinger, Finegan, & Wilk, 2009). Nurse managers are the link that creates a supportive, collegial, and collaborative environment; they foster professional practice and are essential in moving nursing into the future as leaders, role models, and active members of the interprofessional team. Laschinger’s research over the years has revealed that the role of nursing leadership is important in creating an empowering work environment. Additional studies have found that staff nurses, who perceive their managers as powerful leaders, also view their work environments as empowering. This is reflected in their professional practice through increased patient satisfaction ­(Laschinger, Wong, Grau, Read, & Stam, 2011) and positive health outcomes (Armellino, Griffin, & Fitzpatrick, 2010).

BASIC DESCRIPTION OF THE THEORY Empowerment throughout the literature is viewed as the ability to get things done in an organization. It is an important motivational tool for employees who are dedicated to their institution. The literature supports that several distinct perspectives of empowerment exist. According to Trus, Razbadauskas, Doran, and Suominen (2012, p. 412), the three theoretical approaches most often used in published works are critical social theories, social psychological theories, and organizational and management theories.

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The first perspective is based on critical social or feminist theory and is associated with the improvement of conditions of oppressed groups (Kuokkanen & Leino-Kilpi, 2000). The critical social theory explains how disadvantaged groups are in a subordinate position struggling to improve their situation and attain liberation (BradburyJones, Sambrook, & Irvine, 2007). In the context of nursing, the use of empowerment from a social critical standpoint can be understood based on the historical role of nurses and the social structure they find themselves in as subordinates among administrators, patients, and other health care professionals (Trus et al., 2012). The second perspective is psychological empowerment (Spreitzer, 1995) and has its foundation in social psychological theory. Empowerment from a psychological outlook is viewed as the perceptions or attitudes of individuals toward their work and their role in the organization (Spreitzer, 1995). Nursing research has viewed empowerment as either related to the environment (Laschinger, Finegan, Shamian, & Wilk, 2001) or developing from one’s psychological state (Manojlovich, 2005; Spreitzer, 1995). Psychological empowerment was first identified in the literature by Conger and Kanungo in 1988. This theory was partially based on Bandura’s theory of self-­efficacy (1977) and originally defined as a “process of enhancing feelings of self-efficacy among organizational members through the identification of conditions that foster powerlessness and through their removal by both formal organizational practices and informal techniques of providing efficacy information” (Conger & Kanungo, 1988, p. 474). Spreitzer (1995) further developed the concept of psychological empowerment and later defined it as a motivational construct manifested in four cognitions: meaning, competence, self-determination, and impact. This theory proposes that individuals who believe in their chances of success have a greater likelihood of succeeding. Empowered staff are more likely than nonempowered staff to exhibit behaviors that maintain their professionalism, even when faced with challenging situations in the workplace. Nurses’ perceptions of their structural and social environment can create a greater impact in the process of their personal growth and professional development (Trus et al., 2012). This relationship between social and structural environment leads to the third perspective that describes empowerment from organizational and management theories. The Structural Empowerment Theory, originally published by Rosabeth Moss Kanter in 1977 as an organizational theory, was intended to explore how consciousness and behaviors are shaped by positions held in organizations. Her goal was to showcase the difference of how men and women are “products of their circumstance” and are limited by the roles they have in an institution (Kanter, 1993). Her desire was to explore ways to help change the work culture to make improvements in both quality of work life and organizational effectiveness (Kanter, 1993). The women’s movement of the 1970s greatly influenced Kanter’s thinking; she strove to better understand the fate of women in organizations. This original idea, along with other research projects, led her to work as an outside consultant at a company called Industrial Supply Corporation (Indsco), a pseudonym for a very large manufacturing company in the United States. During this time, Kanter’s theory of empowerment began to become a reality. Her participant observations of work organizations, the conceptions of roles and how they defined the people within them, and how they shaped behavioral outcomes all led to the development of the Structural Empowerment



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Theory. Her perspective of an employee’s advancement was based on work conditions and perceived power—not on personal attributes. Laschinger, Wong, McMahon, and Kaufmann (1999) found that leaders’ empowering behaviors—such as enhancing the meaningfulness of work, fostering participation in decision making, facilitating goal accomplishment, expressing confidence in high performance, and providing autonomy from bureaucratic constraints—were associated with greater feelings of empowerment by nurses in acute care settings.

CORE CONCEPTS According to Kanter’s (1977, 1993) model of organizational empowerment, structural concepts within the work environment have a larger impact on an employee’s work attitude and behavior than personality or socialization experiences. She describes four organizational empowerment structures: access to information, support, resources needed to do the job, and opportunities to learn and grow. Access to information is described as having the knowledge needed to be effective in a person’s role. This includes knowing about organizational decisions, policies, and goals as well as data. It also encompasses technical knowledge and expertise required to be effective in positions in the institution. Information fosters a sense of belonging and purpose for an employee; it encourages engagement and allows employees to make informed decisions that contribute to the organizational goals. Leaders perceived to be powerful are given access to more resources such as money, supplies, time, and equipment, which provides employees with the necessary tools to accomplish their jobs and meet their institutions’ objectives. Support in the form of guidance or coaching received from supervisors, peers, and subordinates can provide an employee with the confidence to advance. This may be in the form of emotional support, helpful advice, or hands-on assistance. Access to opportunities refers to an individual’s expectations and future prospects for advancement, inside or outside the organization (Almost & Laschinger, 2002). This can be either in the form of career advancement or professional growth that cultivates increased knowledge and skills. Furthermore, this may be accomplished through participation in work committees, task forces, or interdepartmental work groups that provide opportunities to work with people in other areas of the organization. Kanter (1979) conceptualizes power as the “ability to mobilize resources to get things done” (p. 210) and uses the analogy of an electrical circuit to describe how productive power is achieved and maintained in the work setting. Power is on when employees have access to lines of information, support, resources, and opportunities to learn and grow. When these “lines” or sources of power are unavailable, power is off and effective work is impossible. These lines of power are sources of structural empowerment within the organization. Power systems, formal and informal, provide access to committees that can be viewed as empowerment structures. “Formal power is enhanced when jobs are flexible, central to the organization’s goals, and support employee creativity and discretionary decision making. Informal power is derived from effective relationships and communication channels with sponsors, peers, and subordinates both within and outside the organization” (p. 542) where alliances and relationships are formed at

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different levels (Laschinger, Wong, & Grau, 2013). These informal alliances enable staff to navigate within the system in achieving set goals and getting the work done. Employees who feel the lack of access to resources, information, support, and opportunity often feel powerless and disengaged. This sense of being disenfranchised and excluded from decision making can lead to frustration, burnout, and lack of opportunities for upward mobility in the organization. In contrast, employees who are given access to data are engaged, demonstrate autonomy, and see a future in the institution. Spreitzer (1995) suggested that psychological empowerment is the emotional investment needed for staff members to be successful. The process of psychological empowerment is influenced by their work environment and is demonstrated in four core concepts: meaning, competence, self-determination, and impact. Meaning is individuals’ buy-in that their purpose and role and responsibilities are meaningful and an important factor to their work environment. Competence is people’s beliefs that they are capable of doing their job well and are able to complete the task at hand. Self-determination is when individuals feel they have autonomy in their work responsibilities and control over their contributions to the job. Impact is the feeling of participating in important decisions influencing their organizations’ outcomes. Positive relationships can be seen between the core concepts of structural and ­psychological empowerment and their influence on empowering behaviors. ­Spreitzer (1995) suggests that an environment with a solid foundation of the struc­ tural and psychological core concepts alone does not necessarily promote an empowered staff. It is important that individuals are engaged and understand that their work has impact and is meaningful. The encouragement of an empowering environment also fosters individuals’ perceptions of competence and self-efficacy, which provide them with the confidence to believe that they are able to meet the demands of the job. Information about an organization’s vision is essential in helping to create a sense of meaning and purpose (Conger & Kanungo, 1988). It also enhances the individual’s ability to make influential decisions that are appropriately aligned with the organizational goals and mission. This access to data vitally impacts employees’ ability to not only do their jobs well but to feel a sense of belonging to an institution. This sense of belonging enhances meaning in individuals’ roles and therefore increases self-­efficacy. This also provides them with information, leading to potential opportunities for career growth and development within the institution. According to Spreitzer (1996), well-informed employees feel more competent in their roles, generating higher satisfaction and greater organizational impact. Nurses’ power may arise from three components: a workplace that has the requisite structures that promote empowerment where their role is integral to the organization; a psychological belief in one’s ability to be empowered to influence decisions, motivate change, and make a profound contribution to the institution and health care in general; and acknowledgment that there is power in the relationships and the care that nurses provide where their own self-worth is valued by peers and patients (Manojlovich, 2007). Power exists in society and in organizations both formally and informally. Formal power is relative to the level of one’s position within an organization, and informal power is based on relationships and the influence one can exert or the action one can motivate by virtue of those relationships (Kanter, 1977, 1993; ­Laschinger, Purdy, Cho, & Almost, 2006; Rao, 2012). Nurse managers attain formal



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power by virtue of their roles, and have the capability of accessing necessary information, resources, and support—thereby providing staff with the necessary tools to excel in their jobs. This formal power is an essential tool that enables staff and gives them the support and confidence to build relationships with people at different levels in the institution. These relationships can influence the staff’s work attitude, behavior, and commitment to the organization, which has an indirect relationship to satisfaction and positive patient outcomes. “Power is an attribute that nurses must cultivate in order to become autonomous because it is through power that members of an occupation are able to raise their status, define their area of expertise, and achieve and maintain independence and influence” (Manojlovich, 2007, p. 3).

RESEARCH FROM OTHER DISCIPLINES RELATED TO THIS THEORY Interest in empowerment started gradually; however, since the early 1970s it has changed from a new and challenging concept to a highly popular and mainstream theory used in many different disciplines. Empowerment has been seen in psychology, sociology, education, and management literature. It also has been used in a variety of studies ranging from exploring the effects of empowering marginalized groups in a community, to employees in the management and leadership field, and eventually to health care.

Marginalized Group in a Community According to Lee, Weaver, and Hrostowski (2011), “Studies of both for-profit and non-profit organizations have consistently reported that workers who feel a high sense of psychological empowerment at work are more likely to have a sense of control and competence, report a sense of ownership when answering questions about their tasks, and experience high levels of job satisfaction and/or commitment to their organization” (p. 480). As reported by the Child Welfare League of America (CWLA, 2002), public child welfare workers face difficult challenges every day with expanding and complicated caseloads, which lead to emotional fatigue and increased turnover. This report led to a study of the effects of psychological empowerment on child welfare workers (Lee et al., 2011). The research explored how work environment (quality of supervision and role ambiguity) and psychological empowerment are related to case worker retention in public child welfare. The goal was to determine the degree in which “psychological empowerment mediated the relationships between work environment variables (quality of supervision and role ambiguity) and worker outcome variables (emotional exhaustion and intentions to remain employed in child welfare)” (p. 479). The results from 234 public child welfare frontline workers revealed that the “quality of supervision and psychological empowerment were directly related to workers intentions to remain employed in child welfare and an indirect relationship between quality of supervision and intentions to remain through the mediating variable of psychological empowerment was found” (p. 489). An indirect relationship was also found between emotional exhaustion and psychological empowerment. Similar to studies that have been conducted in the acute care hospital setting, case workers who feel supported and understood by their supervisors remained positive and committed to their careers as child care welfare workers.

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Management and Leadership Field Empowerment has been described in management literature as crucial to the life of an organization during times of change and global competition (Rao, 2012; Spreitzer, 1995). Smith (2008) studied the impact of structural empowerment on a project manager’s organizational commitment. A project manager’s effectiveness is influenced by the perceived amount of control, type of power, and level of empowerment. This empirical investigation examined the forms of empowerment and work effectiveness among 79 project managers at a Project Management Institute (PMI) workshop. Results of the study indicated that, overall, project managers did not perceive themselves as empowered on a formal level. They felt their jobs did not allow them to make important decisions, or they felt that their positions were insignificant in the organization. However, interestingly, their perceived empowerment at the informal level—described as influential partnerships formed in the workplace—was above average. In terms of the opportunity of the work effectiveness variable, they were above average; however, three of the four components of the work effectiveness variable were below the scale average. These findings suggest that project managers perceived themselves as having only a slight chance for obtaining relevant information, access to necessary resources, and help from colleagues to complete a project. Generally, the results of the study agreed with Kanter’s (1993) suggestions that employees display a stronger commitment to an organization when they have adequate opportunities, information, resources, and support. According to Smith (2008), understanding the relationship of the work effectiveness variables of organizational empowerment to employees’ commitments may help an institution attain the desired levels of productivity and outcome objectives. In the educational world, teacher satisfaction directly influences school effectiveness and student performance. Bogler and Nir (2012) collected data from a sample of 2,565 teachers affiliated with 153 Israeli elementary schools to test the “mediating effect of teacher empowerment on the relation between the perceived organizational support and job satisfaction. Studies have shown empowered teachers have higher levels of job satisfaction” (p. 287). They found that self-efficacy directly impacts teacher satisfaction. Bogler and Somech (2004) reported that empowering teachers can enhance their job satisfaction, which can result in increased commitment to the school and ultimately to their profession. The results from research reviewing the responses of 348 charter school teachers on empowerment leadership and intentions to stay revealed that “leadership is a stronger predictor of charter school teachers’ intentions to stay in their current school or to leave the school, district, state, or the profession altogether than is empowerment” (Ndoye, Imig, & Parker, 2010, p. 180). In addition, the specific items on leadership and empowerment provided insight on what mattered most to the teachers. It was reported that trust, mutual respect, collaborative problem solving, and supportive leadership all attributed to their commitment to their school and their intent to stay (Ndoye et al., 2010).

Health Care Mislevy, Schiller, Wolf, and Finn (2000) used Kanter’s theory of organizational empowerment in a descriptive research study to determine nutrition managers’ perceived access to sources of power: information, support, resources, and opportunities.



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The Conditions of Work Effectiveness Questionnaire (CWEQ) was sent to a random sample of 348 members of the Clinical Nutrition Management Dietetic practice group of the American Dietetic Association (ADA). Overall, the study results showed that clinical nutrition managers perceived themselves as being empowered and with substantial access to information. They appeared to have considerable access to data, opportunities, resources, and support needed to function effectively as leaders within the scope of their responsibilities. Mislevy et al. (2000) stated, “Clinical nutrition managers’ perception of organizational empowerment compare favorably with perceptions of staff nurses and nurse managers” (p. 1042). The important result found from this study was that the outlook of clinical nutrition managers viewing themselves as being empowered is of value to the future of the dietetic profession. In an effort for dieticians to be successful in the present health care arena, individual empowerment is the key element that is needed for them to assume strong leadership roles. Kanter’s theory was additionally used by Miller, Goddard, and Laschinger (2001) to examine the perceptions of empowerment in physical therapists—a still not well-studied area. The results from a convenience sample in a large urban Canadian hospital revealed scores similar to nurses’ views of access to support, information, resources, and opportunity. However, the scores were higher than for the majority of reported staff nurses and managers for access to sources of informal and formal power structures. Kanter’s theory can provide physical therapists and their managers with a helpful framework to access information about the sources of empowerment that are needed to thrive in an organization. The literature has identified a link between patient empowerment and positive patient outcomes. McGuckin, Storr, Longtin, Allegranzi, and Pittet (2009) defined patient empowerment as “a process in which patients understand their opportunity to contribute and are given the knowledge and skills by their health care provider and other educational sources to perform a task in an environment that recognizes community and cultural differences and encourages patient’s participation” (p. 11). In recent years, there has been a push for patients to speak up and ask health care workers to wash their hands before treating them. Even with best-practice ­initiatives— which have been around for some time—focusing on hand hygiene, compliance with the practice has still remained low, despite being a major patient safety issue. ­McGuckin et al. (2009) developed a patient empowerment model, with a brochure focusing on educating patients about hand hygiene including why, where, when, and by whom hand hygiene should be performed. Empowering patients to speak up and take control of their care has helped push this important initiative to the forefront and should hopefully increase compliance among health care providers.

RELATIONSHIP OF THE THEORY TO NURSING METAPARADIGM CONCEPTS Historically, the nursing discipline was viewed as a helping profession that focused on the interpersonal relationship between nurse and patient. There were several different views of the nurses’ role but they were primarily viewed as “enabling the will and behavior of the person who is receiving the care” (Chinn, 2011, p. 47). According to Falk-Rafael (2001), nurses regarded empowerment as a development process

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ingrained in each individual’s values, beliefs, and culture. Active participation was an essential element of this technique; nurses “could only facilitate, not create empowerment” (p. 4). The nurse is an advocate and uses her existing knowledge to educate patients about their health needs. Nurses empower patients with the knowledge to make informed decisions. Participative decision making can empower the nurse as well as the patient if they are equal partners in decisions being made about the care delivered. With this outlook on nursing, the nurses’ actions are reflective of their intuition, initiative, knowledge, and approach. This idea arose from the perspective emphasizing that nursing actions are essential to reach the goals of the nurse–patient relationship and interaction. The term to empower has traditionally been described as giving authority to another person or investing power in others. When used within the health care context, empower can be viewed as an unequal relationship between a subordinate and a superior, typically seen among administrators, physicians, and nurses (Trus et al., 2012). The imbalance of power is attributed to competing goals, coexisting layers of authority, and rigid hierarchical structures that prevent nurse managers from exerting their authority and expanding their clinical practice. Organizations need to install measures that allow nurse managers a span of control over their work environment, support their domain of authority, and value their contribution to patient care and positive health care outcomes. Nurse managers need to have a clear understanding of the operational definition of empowerment as it relates to their position and role in order to be effective, empowered leaders. Empowered nurse managers are more likely to promote empowerment in the workplace, thus making the practice of empowerment “contagious” and becoming role models for staff (Laschinger, Gilbert, Smith, & Leslie, 2010). Trus et al. (2012) explained that as a result of experiencing empowerment within their roles, nurse managers and staff can foster a strong sense of self-esteem, greater work performance, and progressiveness. When caring for an individual, the whole person needs to be considered—not just the components. The metaparadigm concept of human beings refers to people. Individuals should be recognized in a culture, as well as in families, communities, and other groups or aggregates that are participants in nursing. Staff nurses are co-­ participants with patient care and also need to be considered. The nature of empowerment as a collective activity increases access to knowledge and provides resources for groups and communities similar to the interactive method of nurses working with individual patients to manage chronic illness and achieve a successful aging process (McCarthy & Freeman, 2008). Fawcett (2005) describes human beings connecting with the environment through all local, regional, national, and worldwide cultural, social, political, and economic conditions. Environment is often referred to as the physical surroundings as well as the settings in which health care and nursing care occur—which could take place in various settings ranging from home, community, or hospital. Regardless of the setting, the main priority for nurses is providing safe and quality care that complies with standards and health care regulations. According to a report from the Institute of Medicine (IOM) (2003), “the quality of patient care is directly influenced by the degree to which nurses are empowered participants in making active decisions and addressing issues affecting their environments of practice.” A key aspect of the nurse manager role is to create conditions that empower nurses to provide the best possible care for their clients/patients within an environment that fosters professional practice and effective working relationships (Laschinger et al., 2010, p. 5). As a result,



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nurses are able to help patients effectively cope with chronic illness and empower them to advocate for their needs within their current health care environment. The health metaparadigm concept can be viewed as a dynamic process that changes with time and varies with life circumstances and illness. Nurses can strive to empower patients to make their own health care decisions, especially if their choices are not health-promoting behaviors or compliant with medical regimen. It is important for nurses to empower patients to make their own health care decisions, even if the nurse does not agree with the patient’s choices.

THEORY ANALYSIS Several studies have used the theory of empowerment to understand its influence on nursing practice. Nurse researchers such as Laschinger, Kuokkanen and LeinoKilpi, and others have done numerous collaborative studies in understanding the importance of providing a work environment that promotes empowerment for nurses who are either in middle management or leadership positions. The Empowerment Theory has been extensively researched within the nursing profession, and has shown a strong link between structural and psychological empowerment and relevance to healthy and productive work environments and positive patient outcomes, as evidenced by the work done by Purdy, Laschinger, Finegan, Kerr, and Olivera (2010). “Empowered nurses are eager to implement evidenced based practice, they are highly motivated, well informed and committed to organizational goals and thus deliver patient care with greater effectiveness” (Kuokkanen & Leino-Kilpi, 2000). Research has shown that nurses who feel their work environment is empowering are more satisfied with their jobs (Laschinger et al., 2001), feel more effective in accomplishing their work (Bobbio, Bellan, & Manganelli, 2012), and report higher levels of patient care quality on their units (Purdy et al., 2010). Higher levels of empowerment have also been linked to greater feelings of respect in the work setting and higher levels of trust (Faulkner & Laschinger, 2008; Laschinger & Finegan, 2005). Research has also shown that empowered nurse managers are more likely to empower their staff (Haugh & Laschinger, 1996). To empower others, managers themselves must be empowered (Laschinger & Shamian, 1994; Patrick, Laschinger, Wong, & Finegan, 2011), as well as being perceived as empowered by their staff (Patrick et al., 2011). Only a few studies have examined the effect of staff nurse empowerment on patient outcomes (Donahue, Piazza, Griffin, Dykes, & Fitzpatrick, 2008; Hatler, 2006; Purdy et al., 2010). Much of the research exploring empowerment in the health care setting utilizes the Conditions of Work Effectiveness Questionnaire-II (CWEQ-II). The CWEQ-II consists of 19 items that tap the six empowerment structures described by Kanter: resources, support, information, opportunities to learn and to grow, formal power, and informal power. Items are rated on a five-point Likert scale. Laschinger et al. (2001) validated the factor structure of these empowerment measures and, based on these results, a total empowerment score was created by summing the six subscales of the CWEQ-II (score range: 1–5). This tool has helped to operationalize the theory of empowerment in the clinical setting. The theory of empowerment has clearly demonstrated the phenomena of structural and psychological empowerment and their relationship to the leadership of nurse managers. The following publications support the descriptions of the theory

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that validate the hypothesis and are supported by empirical research: Patrick et al. (2011) developed a clinical leadership survey that measures the ability of the staff nurse leadership skills; Faulkner and Laschinger (2008) looked at the effects of structural and psychological empowerment in an acute care nurse’s perception of respect. In relation to practice, the assumptions that the theory suggests as supported by the research are demonstrated in positive patient outcomes and staff satisfaction and retention. The IOM recommended empowering all members of the health care team to engage staff in creating a culture that promotes patient safety. This is further validated by Purdy et al. (2010) and their work involving the effect of empowerment and the importance of consistent workplace strategies to promote staff and patient satisfaction. Using the evaluative criteria by Fawcett (2005), additional information from previously ment